THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


ST.   JOHNS 
MEDICAL    LIBRARy, 
SANTA   MONICA 


STUDIES  IN 

THE  ANATOMY  AND  SURGERY 

OF  THE  NOSE  AND  EAR 


f  rop*rty  •• 
ST.  JOHNS 

MEDICAL   LIBRAR> 
SANTA   MONICA 


STUDIES  IN 

THE  ANATOMY  AND  SURGERY 
OF  THE  NOSE  AND  EAR 


BY 
ADAM  E.  SMITH,  M.  D. 

past  Chiet  Medical  and  Sanitary  Officer,  Nile  Reservoir  Works.  Assuan,  Egypt; 

Past  Instruc»3r  m  Operative  Surgery,  Columbia  L'niversity  Medical  College; 

Past  Attending  Surgeon,  German  Hospital,  O.  P.  D.,  New  York  City 


^- 


'A 


\S 


NEW  YORK 

PAUL  B.  HOEBER 
1918 


Copyright,  1918 

By  Paul  B.  Hoeber 

Published,  February,  IQ18 


Printed  in  the  United  States  of  America 


DEDICATED,  IN   LOVING  MEMORY, 
TO     MY    FRIEND     AND     TEACHER 

DR.  FRANK   HARTLEY, 

OF    NEW    YORK, 

AN  ARTIST  OF  THE  HIGHEST 
ORDER  IN  HIS  CHOSEN  SPECIALTY 
AND  A  SOURCE  OF  CONSTANT  IN- 
SPIRATION TO  HIS  PUPILS  AND 
COWORKERS 


I'l 


l'RI-:i'ACE 

This  little  vulunic  deals  with  the  anatcmu-  i)t  tlie  iidse  and  ear  fr<.)ni  a 
surgical  standpoint.  The  illustrations  were  made  directly  from  dissections 
prepared  by  the  author  and  drawn  with  great  accuracy  under  my  supervision 
by  Air.  Martin  Peterson  of  the  Anatomical  Department,  Columbia  Univer- 
sity Medical  School.  None  of  the  drawings  are  .schematic  but  represent 
anatomy  from  a  practical  standpoint,  showing  the  relation  of  parts  to  their 
natural  surroundings  and  to  the  head  as  a  whole.  Owing  to  their  accuracy, 
and  their  instructiveness  and  scientific  interest  they  should  have  permanent 
worth,  and  this  is  the  main  reason  for  presenting  the  studies  in  book  form. 

There  are  practical  points  in  treatment  which  are  new  and  novel  based  on 
natural  physical  laws  and  common  sense,  the  \'alue  oi  posture  in  the  treat- 
ment of  otitis  media  and  mastoiditis  being  one  of  particular  interest.  The 
mechanics  of  treatment  by  suctiim,  in  frontal  sinus  and  maxillarv  antrum 
disease,  is  another. 

I  owe  my  original  interest  and  ajipreciation  of  the  subjects  dealt  with 
herein  to  Professors  Krause  and  Katz  of  the  University  of  Berlin,  with 
whom  I  worked  from  1895  to  1897.  My  interest  was  renewed  and  stimu- 
lated during  my  instructorship  in  the  Operative  Surgery  Course,  College  of 
Physicians  and  Surgeons,  New  York  (  1900-191J),  while  working  with  Pro- 
fessor Frank  Hartley,  and  it  is  due  to  his  constant  encouragement  that  the 
contents  of  this  volume  resulted. 

I  desire  to  express  my  gratitude  to  Professor  H.  T.  Brooks  for  his  ever- 
ready  and  painstaking  assistance  in  reviewing  the  text,  and  to  my  wife  whose 
constant  and  untiring  aid  in  taking  dictation  for  manuscripts  and  reading 
proofs  was  a  great  source  of  helpfulness. 

The  publishers  of  the  Aiiwrican  Journal  of  Medical  Sciences,  the  Annals 
of  Surgery,  the  Medical  Record  and  the  Nei^'  York  Medical  Journal  have 
kindlv  jiernutted  me  to  draw  u])(in  material  which  first  appeared  in  their 
respective  iournals  as  original  articles  over  a  period  of  several  years. 

I  am  also  indebted  to  my  publisher  and  his  assistants  for  the  adxice  and 
assistance  in  liringing  out  the  \-olunie  in  its  present  form. 

February,  1918  Ad.\.m  F.  Smith 


CONTEXl'S 

CHAPTER  PAGE 

I.     The  Importance  of  Nasal  Breathing    .....       13 

II.     Some  Suggestions  on  the  Treatment  of  Intranasal  Condi- 
tions    ...........       19 

III.  A  Contribution  to  the  ;\natomv  and  Surgery  of  the  Nose 

and  Its  Sinuses     ........       33 

IV.  Anatomical  and  Surgical  Uesiderata  in  the  E.xposure  and 

Removal  of  the  Pituitary  Gland     .....       94 

V.     Postural  Treatment  of  Otitis  Media  and  Mastoiditis  .         .     loi 

VI.     A  Contribution  to  the  Anatomy  and  Surgery  of  the  Tem- 
poral Bone  ..........     109 

Index .1;^ 


LIST  OF  ILLUSTRATIONS 

PLATE  PACE 

I  and  II.     Instruments  used   fi>r  irriLjatiun  and    auction    trL-atnient    in 

sinus  disease 24,  25 

III.     Symmetrical  sinuses  exposed  in  normal  skull       ....  27 

I\^  and  \'.     Anteroposterior  section  of  skull  exposing  sinuses     .          .  28,  29 

VI.     Same  as  Plate  III 37 

VII  and  \'III.     Skull  with  asymmetrical  sinuses  exposed  ...  39,  41 

IX.  Sypliilitic  skull  showing  erosion  of  interior  of  nose  and  poorly 
developed   sinuses 43 

X.  Dissection  of  large  frontal  sinuses 45 

XI  and  XII.     Same  as  Plates  IV  and  V 46,  49 

XIII   and   Xn'.     \'ertical   section   of   skull   exposing   frontal   sinuses 

and  interior  of  nose 50.  S3 

XV  and  XVI.     Vertical  section  shi)wing  ethnioids.  maxillary  antra 

and  interior  of  nose       .........  54-  57 

X\'II  and  XVIII.     \'ertical  section  showing  same  as  previous  plate, 

one  centimeter  posteriorly 58,  61 

XIX  and  XX.     \'ertical  section  through  midpoint  of  nose  ...  62,  65 

XXI  and  XXII.     \'ertical  section  through  sphenoid  sinuses  and  nose  66,  69 

XXIII  and  XXIV.     \'ertical  section  through  nasopharynx  ...  70,  ~:^ 

XXV.  Horizontal    section    through    skull    showing   interior   of    nose 

and  antra,  seen  from  helow  ........  75 

XXVI.  Lines  of  incision  for  exposure  of  sinuses  and  interior  of  nose  "J 

XX\'II.     Incisions  for  frontal  sinus  and  maxillary  antrum  exposure 

and  osteoplastic  flap  for  frontal  sinus 79 

XX\'III.     Maxillarv  antrum  and  interior  of  nose  exposed  by  means 

of   osteoplastic    flaps        ...             83 

XXIX.     Exposure  of   frontal  sinuses,  ethmoid  cells   and  interior  of 

nose         .........-•■  05 


II 


12  LIST  OF  ILLUSTRATIONS 

PLATE  PAGE 

XXX.  Anteroposterior  section  of  head  showing  incisions  of  nose  and 

septum   for  exposing  pituitary  gland       ......  98 

XXXI.  Line   of   incision    for  osteoplastic   flap    for  exposing  interior 

of  nose  ............  99 

XXXII.  Base  of  skull  seen   from  above  exposing  antrum,  tympanic 

cavity  and   Eustachian   tube   ........  105 

XXXIII.  Line  of  incision  f(jr  simple  and  radical  mastoid  operations  112 

XXXIV.  Exposure  of  tympanic  membrane  and  mastoid  region  .         .  114 

XXXA'.  Exposure  of  middle  ear  showing  ossicles  and  "mastoid  quad- 
rants"        116 

XXX VL     Exposure  of  middle  ear,  mastoid  antrum  and  lateral  sinus  118 

XXX\'II.  Exposure  of  middle  ear  with  ossicles  removed,  antrum, 
sinus  and  line  of  incision  for  extended  exposure  of  horizontal 
portion  of  lateral  sinus  .........  124 

XXX\TII.     Exposure  of  facial  nerve,  trephine  opening  in  squamous 

plate  and  interior  of  lateral  sinus  .......  126 

XXXIX.  Dissection  of  facial  nerve  showing  aquasductus  Fallopii, 
external  semicircular  canal  and  osteoplastic  flaps  for  exposure 
of  cerebral  and  cerebellar  convolutions  ......  128 

XL.     Deep  dissection  of  temporal  bone       ......  134 

XLI  and  XLII.     \'ertical  section  of  head  through  middle  and  inner  ear     138,   141 

XLIII.  Base  of  skull  seen  from  above  with  dissection  of  petrous  por- 
tion  of   temporal   bone   .........  144 

XLIA'.  Anteroposterior  section  of  head  through  middle  ear  and  semi- 
circular canals,  showing  relation  of  ear  to  brain  ....  146 

XLV.     Figure  of  skull  showing  Chipault's  method  of  brain  localization  152 


I 

THE  IMPORTANCE  OF  NASAL  BREATHING 


Till-:  IMPORTANCE  OF  NASAL  BREATHING 

For  several  years  past  much  attention  lias  been  given  U>  tlie  importance 
of  the  removal  of  superabundant  adenoid  tissue,  which  is  looked  upon  as  the 
causative  factor  for  all  ills  which  really  are  due  to  defective  nasal  breathing 
and  without  a  conception  cf  the  true  relatiim  nf  the  various  fact(jrs  in\-iilved. 
I  will  here  dwell  particularK-  on  the  great  inii)urtance  and  marked  inthience 
of  air  pressure  upon  the  internal  structures  of  the  nose  during  normal  breath- 
ing and  the  serious  consequences  which  result  when  nasal  breathing  is  not 
persisted  in. 

A  person  breathing  constantly  through  the  nose  has  nostrils  of  sufficient 
size  to  accommodate  a  volume  of  air  to  expand  the  hmgs  to  their  full  capacity. 
Vibriss?e  are  present  to  keep  out  the  gross  pai"ticles  of  dust.  The  nasal  fossas 
within  show  a  sufficient  height  with  a  low  floor  corresponding  to  the  properly 
flattened  palate,  and  the  lateral  walls  are  pushed  sufficientK-  far  out  to  give 
roomy  fossae  on  either  side  of  the  septum.  Where  a  de\iatii)n  of  tlie  septum 
exists  the  lateral  wall  of  the  corresponding  side  is  made  to  encroach  upon  the 
maxillary  antrum  of  that  side  in  order  to  admit  the  rerpiired  volume  of  air, 
the  parchmentlike  bone  of  the  lateral  wall  receding  before  this  continuous 
pressure  of  air,  thus  contributing  one  of  the  various  factors  in  the  production 
of  asvmmetrx'  in  the  sinuses.  The  current  of  air  passing  backward  draws  the 
warmed  air  from  the  sinuses  and  becomes  moistened  and  purified  ( filtered ) 
by  passage  over  the  ciliated  epithelium  of  the  nasal  membrane.  On  expiration 
the  air  heated  and  moistened  in  the  lungs  passes  out  through  the  nose:  part 
of  it  is  forced  into  the  sinuses  as  a  reserve  for  the  next  inspired  air.  which 
should  be  warmed  and  moistened  before  entering  the  lungs.  Hence,  the 
sinuses  are  the  reserve  chambers  to  warm  the  respired  air,  besides  helping 
to  reduce  the  weight  of  the  skull  and  giving  resonance  to  the  voice.  The 
openings  to  these  sinuses  are  placed  high  up  in  protected  places  ideally 
situated  to  prevent  extraneous  matter  from  entering  them  and  thus  pre- 
venting their  infection.  The  lining  membrane  which  contains  the  blood 
supply  for  their  bony  walls  gives  off  only  sufficient  moisture  to  preserve 
this  structure. 

The  volume  of  air  passing  through  the  nasal  fossje  from  infancy  onward 
exerts  marked  pressure  on  all  the  structures  within  the  nose,  pushing  the 

15 


i6     ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

lateral  walls  outward  and  the  floor  downward  sufficiently  to  give  the  space 
required  for  the  growing  capacity  of  the  lungs.  The  low  floor  corresponds 
to  the  properly  flattened  roof  of  the  mouth,  the  wide  alveolar  process  allow- 
ing the  teeth  to  develop  without  crowding.  The  air  normally  conducted 
through  the  nose  and  nasopharynx  will  produce  suHicient  pressure  to  support 
the  vessels  in  the  adenoid  tissue  normally  present  in  the  nasopharynx  and 
hence  keeps  its  growth  within  bounds.  The  nasopharynx  is  commodious, 
gives  the  palate  a  wider  range  of  motion,  and  adds  to  its  mobility, — -a  factor 
in  jiroper  enunciation. 

To  overcome  the  resistance  offered  by  the  comparatively  small  entrance 
which  the  anterior  nares  present  for  the  large  quantity  of  air  to  fill  the  lungs, 
the  muscles  of  respiration  are  brought  into  play  for  the  uniform  expansion 
of  the  entire  chest  and  lungs.  A  great  quantity  of  blood  is  thereby  drawn 
into  the  chest  which  Ijalhes  the  lung  tissue,  thereby  tending  to  preserve 
its  health  fulness  and  also  to  increase  the  exchange  of  gases,  and  hence  estab- 
lish Ijetter  metabolism  throughout  the  body. 

Against  all  this  let  us  compare  mouth  breathing.  The  neglected  nostrils 
are  collapsed  from  disuse.  The  absence  of  air  pressure  within  the  nose  has 
permitted  the  fossfe  to  remain  narrow.  If  they  are  sufficiently  roomy  the 
mucous  membrane  covering  the  turhinals  is  swollen  from  nonsupport.  From 
the  same  lack  of  pressure  the  floor  of  the  nose  has  not  been  depressed,  re- 
sulting in  the  high  vaulted  palate,  the  contracted  alveolar  process,  and  irregu- 
larity in  the  position  of  the  teeth.  The  upper  jaw  and  lip  are  pushed  forward 
and  the  lower  lip  droops  and  is  thickened. 

At  this  point  T  desire  to  take  exception  to  the  accepted  theory  of  Lombroso 
that  the  vaulted  palate  is  a  distinctive  mark  of  degeneracy  and  substitute  the 
above  explanation  as  the  true  cause  of  that  deformity. 

In  those  in  whom  there  is  an  abundance  of  adenoid  tissue  lining  the 
nasopharyngeal  wall,  the  vessels  of  this  tissue  being  unsupported  are  con- 
tinually in  a  congested  state.  Added  to  this  is  the  negative  pressure  or  suction 
resulting  from  the  air  sweeping  through  the  mouth  down  the  pharynx,  con- 
stituting a  second  factor  in  the  production  of  hyperemia  of  the  adenoid 
tissue,  both  factors  resulting  in  the  true  cause  for  the  superabundant  growth 
of  that  tissue.  The  adenoid  tissue  which  occludes  the  postnasal  space  inter- 
feres with  the  proper  aeration  of  the  middle  ear  through  the  Eustachian  tube, 
producing  defective  hearing,  ami  interferes  with  the  proper  function  of  the 
soft  palate  which  so  often  is  manifest  in  young  children  and  frequently  is 
the  only  cause  for  their  defective  speech,     ^\'ith  the  disturbed  circulation  in 


ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR  17 

the  nose  and  nasopharynx  tiic  circnlati<in  at  the  hase  of  the  brain  is  affected, 
influencing  the  mentahty  of  tlie  numth  l)reather,  who  fre(|nenlly  is  put  down 
as  a  dullard  at  school. 

The  dust  laden  and  infected  air  passes  through  the  mouth,  producing  dry- 
ness, infecting  and  inflaming  the  tonsils  and  pharynx,  eventually,  permanently 
enlarging  the  tonsils  through  repeated  insult  and  increasing  the  liability  to 
circumtonsillar  infections.  On  account  of  the  large  opening  which  the  mouth 
presents,  no  extra  effort  is  required  during  inspiration,  as  is  the  case  when 
the  resistance  of  the  smaller  aperture  of  the  anterior  nares  must  he  over- 
come; hence  the  muscles  of  the  chest  are  not  brought  into  play  as  in  the 
former  instance,  the  chest  remains  contracted,  and  the  lungs  incompletely 
expanded  and  aerated  especially  in  the  apices.  The  increased  amount  of 
blood  which  should  normally  enter  the  chest  does  not  enter,  leaving  the  lungs 
in  an  anemic  condition  oftentimes  unable  to  cope  with  the  germs  which  enter 
with  the  dust  laden  air.  The  air  passing  into  the  lungs  is  cold,  unfiltered  and 
unmoistened,  chilling  the  lung,  affecting  its  lining  membrane  and  circulation. 
The  deposit  of  dust  which  might  contain  noxious  germs  in  great  numbers 
and  too  numerous  to  be  taken  care  of  by  a  reduced  circulation,  frequently 
results  in  inflammation  and  tuberculosis  of  the  lungs. 

At  night  the  mouth  breather  is  restless  and  suffers  with  disturl)ed  sleep. 
His  head  is  thrown  back,  due  to  the  relaxation  and  shortening  of  the  lower 
jaw  muscles  and  the  tension  of  the  extensors  at  the  nape  of  the  neck.  For 
this  reason  the  mouth  remains  open  in  spite  of  cloth  or  leather  jaw  supports 
which  are  frequently  used  to  overcome  mouth  I:)reathing  at  night.  Besides  the 
increased  drag  on  the  lower  jaw,  there  is  also  added  the  disturbed  circulation 
of  the  head  due  to  its  retroflexed  condition. 

Mouth  breathing  is  due  to  several  causes,  but  in  most  instances  it  is 
purely  a  habit.  In  the  case  of  a  nasal  obstruction  the  amount  of  air  possible 
to  be  drawn  through  tlie  nose  may  be  entirely  inadequate,  and  mouth  breath- 
ing becomes  a  necessity  until  the  obstruction  is  removed.  In  other  cases  it 
occurs  in  constitutions  in  which  the  muscle  tonus  has  been  lowered  in  various 
parts  of  the  body,  resulting  in  relaxed  and  flabby  muscles  and  ligaments. 
When  this  occurs  in  muscles  supporting  the  lower  jaw  (the  temporals,  mas- 
seters,  and  pterygoids),  the  jaw  drops  and  mouth  breathing  occurs  and  be- 
comes a  habit.  The  relaxed  lower  jaw  muscles  remain  shortened,  the  reduced 
traction  on  the  bone  itself  producing  the  small  mandible  and  receding  chin. 
The  drawn  skin  of  the  cheeks,  produced  by  the  dropping  of  the  jaw,  presses  on 
the  superior  alveolar  process,  and  this,  added  to  the  vaulted  palate,  is  a  second 


i8  ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

factor,   producing  the   contracted   alveolar   process   and    irregularity  of   the 
teeth. 

Hence,  the  immense  imp<jrtance  of  unrelaxed  effort  on  the  part  of  physi- 
cian, and  especially  parents,  to  induce  children  from  infancy  up  to  keep  the 
mouth  closed  and  make  every  effort  to  breathe  through  the  nose,  even  if 
obstruction  exists  in  the  form  of  tem])i)rarv  swelling  of  the  nasal  membrane 
or  permanent  obstruction. 

Breathe  through  the  nose,  and  the  air  pressure  will  prevent  the  excessive 
growth  of  adenoid  tissue.  Remove  adenoid  growths  if  they  form  an  ob- 
struction, but  if  nasal  breathing  is  not  persisted  in  after  their  removal  the 
excess  of  adenoid  growth  will  again  take  place. 

Besides  repeated  remonstrance  on  the  part  of  physician,  teacher,  and 
parents,  or  others  in  the  home,  nasal  breathing  can  be  enforced  during  sleep 
by  closing  the  lips  by  means  of  skin  plaster.*  When  this  is  done  sleep  is 
more  peaceful  and  the  head  rests  in  its  normal  position.  The  child  accus- 
tomed to  the  sensation  of  nasal  breathing  at  night  can  be  so  much  more 
readil)'  prevailed  upon  to  persist  in  nasal  breathing  throughout  the  day.  So, 
also,  much  of  the  harm  done  by  neglect  during  the  waking  hours  can  be 
mitigated  l.iy  the  normal   breathing  during  sleep. 

Not  only  can  all  the  ill  effects  of  mouth  breathing  be  prevented,  but  after 
they  have  existed  a  number  of  years  they  can  be  corrected  b}'  the  changed 
mode  of  breathing,  i.  e.,  normal  nasal  breathing.  The  oftentimes  hideous 
phvsiognomv  of  the  former  can  be  remodeled  and  changed  into  a  normal, 
sometimes  even  a  handsome  type,  if  the  error  is  corrected  before  the  firmer 
bones  have  hardened  to  too  great  a  degree. 
*Gold  Beaters  Skin  Court-plaster. 


II 

SOME  SUGGESTIONS  OX  THE  TREATMENT  OF  INTRANASAL 

CONDITIONS 


II 

SOME  SUGGESTIONS  ON  THE  TREATMENT  OF  INTRANASAL 

CONDITIONS 

In  acute  and  clironic  rhinitis  and  nasopharyngitis  more  or  less  frequent 
cleansing  of  the  nasal  cavity  is  accepted  as  a  proper  procedure.  Heretofore 
this  has  been  carried  out  by  the  patient  by  the  use  of  sprays  or  douching  or 
sniffing  of  salt  water  or  of  solutions  with  combinations  of  drugs,  such  as 
sodium  chliirid  and  hicarlxmate  with  buric  acid:  or  as  found  in  the  various 
detergent  solutions  usually  containing  thymol,  eucalyptol,  sodium  chlorid, 
bicarbonate,  and  biborate,  with  or  without  glycerin  and  alcohol.  \N'ith  a  dry 
condition  of  the  membranes,  solutions  containing  glycerin  seem  t"  be  contra- 
indicated  and  solutions  free  from  glycerin  and  alcohol  are  advisalile. 

When  using  the  nasal  douche,  the  i>atient  should  be  instructed  to  hold  his 
head  sideways,  over  a  basin,  instead  of  backwards,  and  to  apply  the  douche  to 
one  nostril  and  permit  the  fluid  to  pass  through  and  run  out  of  the  other  nos- 
tril. The  mouth  should  be  kept  open  in  order  to  fix  the  soft  palate  and  allow 
breathing  to  go  on  through  this  pas.sage.  The  patient  is  cautioned  not  to  swal- 
low, which  wonl<l  relax  the  palate  and  cause  the  fluid  to  enter  the  pharynx 
or  larynx  and  produce  a  paroxysm  of  cough.  After  clearing  the  nose  the 
douche  is  refilled  and  applied  to  the  other  nostril :  the  fluid  then  flows  in  the 
opposite  direction.  This  is  less  harmful  than  the  use  of  an  atomizer,  as 
it  does  not  so  much  injure  the  epithelial  lining.  For  several  years  I  have 
considered  it  essential  in  all  acute  inflannnatory  conditions  of  the  nose  to 
make  topical  applications  by  means  of  a  cotton  applicator,  and  to  avoid 
spraying  or  irrigating,  for  fear  of  conveying  infectious  material  to  the  sinuses 
or  middle  ear  or  both.  For  the  same  reason,  patients  have  been  instructed  in 
the  use  of  the  cotton  applicator  and  \\arned  against  the  dangers  of  douching 
or  spraying  to  which  so  many  >inusitides  and  otitides  are  due.  A  25  per 
cent,  solution  of  argyrol,  with  e(|ual  parts  of  glycerin  in  water,  has  been  the 
disinfectant  most  favored.  This  is  repeated  every  twenty-four  to  forty- 
eight  hours,  according  to  the  acuteness  and  severity  of  the  inflammation. 
Spraying  is  never  resorted  to  without  Ijeing  immediately  followed  liy  suction 
treatment. 

Far  superior  to  anv  spraying  or  douching  of  the  nose  or  the  nasopha- 
rynx, especiallv  for  prolonged  use,  is  the  cleansing  of  the  nose  from  behind 
forward.     This  might  be  called  nasopharyngeal  gargling  and  is  performed 


22  ANATOMY  AND  SUR(.ERV  OF  NOSE  AND  EAR 

as  follows:  After  brushing  the  teeth  and  rinsing  the  mouth,  the  throat  is 
gargled  to  free  it  from  food  particles  and  mucus,  which  would  be  liable  to 
be  projected  into  the  nose.  After  taking  a  long  breath,  a  mouthful  of  the 
cleansing  sulution  chosen  is  taken,  the  head  is  thrown  back,  as  with  ordinary 
gargling,  but  instead  of  fixing  the  palate  and  projecting  the  air  through  the 
mouth,  as  in  ordinary  gargling,  the  palate  is  relaxed  and  the  air  is  blown 
through  the  nose  with  the  same  gurgling  force.  The  fluid  thus  mounts  higher 
and  higher  into  the  nose  until  it  is  discharged  from  the  anterior  nares.  The 
head  is  now  thrown  forward  over  the  basin  to  allow  the  fluid  to  flow  out. 
This  procedure  is  repeated  three  or  five  times  until  the  nose  is  thoroughly 
cleared  and  open.  Spraying  the  nasopharyngeal  space  is  usually  most  unsatis- 
factory on  account  of  the  uncontrollaliility  of  the  soft  palate,  the  constriction 
of  the  nasopharyngeal  space,  due  to  the  spasmodic  contraction  of  the  muscles 
of  that  region,  and  the  possibility  of  trauma  from  upward  projecting  nozzles 
necessary  for  the  purpose.  On  the  other  hand,  the  nasopharyngeal  gargling 
just  described  is  as  harmless  to  all  the  tissues  as  douching  and  far  more  ef- 
fective, because  it  reaches  all  the  crevices  and,  on  account  of  the  natural  slant 
of  the  turbinals,  the  fluid,  passing  from  behind  forward,  cleanses  both  the 
inferior  and  superior  surfaces  of  these  bodies  and  flushes  the  meatuses  as 
well  as  the  septum.  Besides  this  there  is  no  injury  to  the  tissues,  as  with  the 
projecting  spray  or  nozzle  of  the  atomizer.  The  nasopharynx  and  the  pos- 
terior nares,  which  are  the  most  important  places  for  harboring  disease 
germs  and  infectious  material,  are  reached  more  effectively  than  is  possible 
by  any  other  method. 

This  procedure,  so  beneficial  as  a  curative  agent,  is  far  more  so  as  a 
prophylactic  measure.  From  personal  experience  it  has  been  determined  that 
with  its  daily  application  as  a  part  of  the  morning  toilet,  severe  inflammatory 
processes  which  previously  thereto  had  been  of  most  freciuent  occurrence, 
have  been  prevented  and  aborted  over  a  long  period  of  months.  The  pro- 
cedure requires  some  experience  and  skill  before  it  can  be  acquired,  but  if  each 
step  of  the  instructions  is  faithfully  carried  out  and  persisted  in.  success 
eventually  will  come  and  the  benefits  thereby  derived  will  many  times  repay 
the  effort  used  in  acquiring  it. 

The  objection  may  be  raised  that  with  a  forcible  projection  of  fluid 
into  the  nasopharynx  the  solution  might  enter  the  relaxed  orifices  of  the 
Eustachian  tubes  and  cause  middle-ear  infection.  If  any  fluid  should  enter 
the  tube  a  very  simple  procedure  will  withdraw  it.  This  consists  in  com- 
pressing the  nostrils  with  thumb  and    forefinger  of   one  hand  and  at  the 


AXATOMY  AXI)  SL'Klil-'.m'  ol-    XOSl'.  AND  EAR  23 

same  time  swalluwing  a  glass  of  water  witliout  taking  a  hreath.  This  will 
produce  sufficient  suction  to  withdraw  the  duid  and  thus  clear  the  tuljes. 
This  is  tile  niethdd  I  have  used  for  several  years  in  all  (ititis-nicdia  crimes, 
having  it  repeated  trequently  during  the  day  for  clearing  the  tuhes  of  secre- 
tions and  causing  an  exchange  of  air  in  the  middle  ear.  A  milder  degree 
of  suction  can  be  effected  by  compressing  the  nostrils  and  carrying  out  a 
swallowing  movement,  without  the  use  of  a  fluid. 

In  cases  of  severe  rhinitis  due  to  ordinary  infection  or  more  particularly 
to  influenza,  extension  to  the  sinuses  often  occurs.  The  ostia  of  the  sinuses 
are  so  situated,  that  for  ordinary  purposes  they  are  in  the  most  protected 
places  to  prevent  entrance  of  extraneous  matter;  but  if  infection  enters  and 
a  secretion  in  the  form  of  serum  or  pus  is  present,  the  ostia  are  placed  most 
disadvantageously  for  proper  drainage.  Nevertheless,  in  carrying  out  con- 
servative treatment  it  is  possible,  by  resorting  to  the  posture  of  the  head, 
to  have  the  ostia  placed  at  a  most  dependent  point,  and  then  l)y  means  of 
suction,  or  irrigation  and  medication  combined  with  suction,  to  defer  opera- 
tive procedure  or  to  render  such  unnecessary. 

In  inflammations  of  the  nose  that  have  extended  through  the  hiatus 
semilunaris  into  the  nasofrontal  duct  or  into  the  ostium  of  the  maxillary 
antrum  or  through  the  ostium  of  the  sphenoidal  sinus,  I  have  found  the 
following  procedure  most  effective :  The  nasal  membrane  receives  an  ap- 
plication of  one  of  the  penetrating  non-irritating  silver  preparations.  It  is 
then  sprayed  or  douched  with  a  detergent  solution,  as  would  be  done  ordi- 
narily for  disinfection  and  treatment  of  acute  or  chronically  inflamed  mem- 
branes. In  the  case  of  frontal  sinusitis,  cocain  is  then  applied  to  the  region 
of  the  nasofrontal  duct,  particularh-  on  account  of  its  mm-irritating,  astringent 
efifect.  Thereafter  suction  is  carried  out  by  means  of  a  glass  nozzle  and 
suction  pump,  the  former  connected  with  the  latter  by  a  small  piece  of  rubber 
tubing,  thereby  minimizing  the  shock  when  the  piston  is  brought  down.  The 
glass  nozzle  has  an  ampulla  below  which  catches  the  secretions  and  prevents 
them  from  entering  the  pump.  The  amount  of  suction  is  regulated  by  com- 
pressing the  nostril  of  the  other  side,  the  inrush  of  air  counteracting  the 
suction  as  well  as  sweeping  the  secretions  from  the  nostrils  into  the  glass 
nozzle.  The  glass  nozzle  completely  clogs  the  nostril  into  which  it  is  inserted 
and  the  pressure  of  the  finger  against  the  other  nostril  occludes  both  openings, 
preventing  access  of  air  from  this  source,  otherwise  no  negative  pressure 
would  result.  The  patient  is  instructed  to  take  a  few  deep  inspirations 
and  after  expelling  the  air  to  keep  his  lips  tightly  closed.     The  suction  pump 


PLATE    I 


Suction   pump,   glass   nozzle,   probe   cannula,  irrigating  syringes,  trocar  for  maxillary 
antrum,   fraise.  punch   forceps,  cannulae    for  trocar  opening. 


24 


PLATE    II 


Electric  pump  with  special  glass  nozzle  for  suction  treat- 
ment of  nose  and  ear. 


25 


26  ANATOMY  AND  SURGERY  Ol-"   N'OSE  AND  EAR 

is  now  put  into  action  and  continued  until  tiie  patient  sliows  distress  in  the 
region  of  the  sinuses  or  is  again  compelled  to  take  breath.  The  inter\'al  per- 
mits cleansing  of  the  nozzle  which  by  tliis  time  has  received  some  of  the 
secretion  from  the  nose  or  even  from  the  sinus.  The  accompanying  illustra- 
tion (  Plate  II  )  shows  a  more  recent  greatl\-  impro\-ed  nozzle,  the  front  tubing 
of  which  is  flattened  and  can  be  introduced  into  the  depth  of  the  nose,  thereby 
avoiding  the  soft  parts  near  the  orifice  which  clog  the  tip  of  the  ordinary 
glass  nasal  nozzle.  For  of^ce  use  I  have  entirely  replaced  the  hand  pumps 
by  the  more  efficient  electric  suction  pump,  which  does  away  with  the  physical 
exertion  on  part  of  the  surgeon  which  the  hand  pumps  entailed.  The  suction 
is  to  be  repeated  from  four  to  six  times  on  the  affected  side,  or  on  both  sides 
if  Ijotli  sinuses  are  involved.  The  treatment  is  repeated  every  second  or  third 
day  according  to  the  acuteness  of  the  condition.  Relief  usually  is  imme- 
diate and  lasts  for  many  hours,  each  subsequent  treatment  prolonging  the 
time  the  patient  is  free  from  pain.  We  thus  effect  not  only  withdrawal  of 
retained  secretions  and  an  exchange  of  air  in  the  sinuses,  but  also  a  tem- 
porary hyperemia  which  is  most  effective  in  all  inflammatory  processes.  At 
first  only  mucus  from  the  nose  or  mucus,  mucopus,  or  pure  pus  from  the 
sinus  itself  may  appear  in  the  ampulla  of  the  glass  nasal  nozzle.  If  pure 
pus  appears  at  the  first  and  the  second  treatment,  this  is  rapidly  changed  on 
subsequent  treatiuents  to  mucopus  or  pure  mucus  with  a  corresponding  relief 
of  pain  or  discomfort  over  and  within  the  sinus.  The  patient  is  instructed 
repeatedly  to  use  suction  at  home  by  means  of  compressing  the  nostrils  and 
swallowing  with  or  without  fluids.  This,  with  internal  medication  in  the 
form  of  salicylates,  purging,  drinking  of  alkaline  waters,  douching  or  gargling 
the  nose,  and  the  application  of  heat  or  cold  to  the  afifected  sinus  will  efifect 
a  rapid  cure.  The  patient  is  also  instructed  to  expose  the  face  to  the  direct  rays 
of  the  sun  for  several  hours  dailv. 

In  the  treatment  of  inflammation  of  the  maxillary  antrum  a  similar  pro- 
cedure is  carried  out,  and  here  the  location  of  the  opening  of  the  sinus,  being 
situated  at  the  upper  inner  angle  of  the  sinus  and  reijuiring  a  dependent 
position  of  the  head  if  drainage  through  the  ostium  is  to  be  ei¥ected,  is  taken 
into  consideration.  During  suction  the  patient  must  lie  on  his  side  with  the 
head  as  low  as  is  consistent  with  comfort,  the  affected  side  being  uppermost, 
the  nianeu\ers  with  the  suction  pump  and  nozzle  being  the  same  as  described 
for  the  frontal  sinus.  The  posture  for  effective  suction  treatment  with  sphe- 
noidal sinusitis  should  be  with  the  head  forward  and  low  down,  the  ostium 
being  situated  well  up  on  its  anterior  wall.     If  suction  and  cleansing  and 


PLATE   III 


A,  Probe  cannula  passed  through  infunciibuluni  and  nasofrontal  duct  into  frontal  sinus. 
B,  Ostium  of  maxiUary  antrum  is  seen  at  upper  inner  angle  of  sinus.  C,  C,  Eth- 
moidal cells  are  seen  with  orbital  wall  removed. 


27 


PLATE   IV 


Middle  turljinal  removed  to  show  probe  cannula  (A)  passing  through  hiatus  semilunaris 
and  infundibulum.  The  frontal  sinus  communicates  with  the  nose  indirectly  through 
the  ethmoidal  cells.  Removal  of  ethmoidal  cells  would  be  necessary  to  penetrate 
into  the  sinus  with  a  cannula. 


28 


it.  JOHHS 


--)lCAL 
-    'TA 


.til 


PLATE   V 


Probe  cannula  (A)  introduced  at  an  angle  of  43°  with  the  floor  of  the  nose  into  the 
ostium  of  the  sphenoidal  sinus.  Section  represents  middle  turbinal.  ethmoid  and 
sphenoid  cells  and  septum  lifted  from  previous  specimen. 


30     AN  ATOM  V  AXD  SURGERY  OF  NOSE  AND  EAR 

internal  medication  do  not  suffice  for  clearing  the  condition,  irrigation  com- 
bined with  (jther  treatment  becomes  necessary. 

In  frontal  sinusitis  a  probe  cannula  with  a  diameter  of  eight  centimeters 
and  bent  in  the  furm  of  a  semicircle  is  introduced,  with  the  aid  of  the  nasal 
speculum  and  good  illumination,  into  the  middle  meatus,  through  the  hiatus 
semilunaris  upward  and  forward  along  the  infundibulum  and  nasofrontal 
duct  into  the  frontal  sinus.  The  end  of  the  instrument  will  be  free  in  the 
sinus  and  ])erniit  thorough  irrigation  and  nie(]icati(jn  of  the  part.  The  can- 
nula should  be  of  the  smallest  size  and  of  good  length,  and  it  is  well  first 
to  jjeml  the  tip  to  conform  to  the  side  of  the  affected  sinus.  Usually  the 
anteri(jr  ])art  of  the  middle  lurbinal  forms  a  fold  or  curtain  or  bridge  where 
it  is  attached  to  the  lateral  wall  of  the  nose.  It  is  behind  this  fold  that  the 
cannula  nuist  pass  into  the  nasotrontal  duct.  Sometimes  the  hiatus  semilunaris 
can  be  seen  for  a  good  distance  upward,  and  the  cannula  can  l^e  introduced 
at  its  upper  part  instead  of  traversing  the  entire  length  of  the  infundibulum. 
The  medicating  and  irrigating  fluids  are  now  introduced  through  the  can- 
nula to  which  a  small  piece  of  rublier  tubing  is  attached.  This  serves  for 
the  easy  application  of  the  sx-ringe,  the  patient  steadying  the  cannula  with 
two  fingers  while  the  irrigating  and  medicating  fluids  are  being  introduced. 
This  is  immediately  followed  by  suction  heretofore  described.  If  introduc- 
tion through  the  natural  passage  is  impossible,  it  is  sometimes  necessary  to 
remove  the  anterior  part  of  the  middle  turbinal,  especially  the  part  forming 
the  bridge  abo\'e  mentioned  and  also  the  air  cells  contiguous  to  the  naso- 
frontal duct. 

In  the  case  of  the  maxillary  antrum  the  probe  cannula  has  its  tip  bent 
at  right  angles  for  a  distance  of  half  an  inch.  This  is  introduced  through  the 
middle  meatus  and  hiatus  semilunaris  to  the  lowest  or  posterior  end  of  the 
infundibulum  to  pass  through  the  ostium  into  the  antrum  itself.  ^Medication 
and  irrigation  are  carried  out  in  the  same  manner  as  in  frontal  sinusitis, 
with  the  patient  in  the  erect  posttire,  and  suction  is  carried  out  in  the  recumbent 
posture  with  the  patient  on  his  side  and  the  head  hjw  down. 

If  a  deca\ed  tooth  projecting  into  the  antrum  is  the  cause  of  the  sinusitis, 
it  will  be  necessary  to  remove  the  offending  root :  but  it  is  preferable  to  make 
the  intranasal  opening  for  treatment  and  drainage  instead  of  a  large  opening 
through  the  socket.  It  is  true  that  in  the  latter  instance  a  more  dependent 
point  in  the  antrum  can  be  reached,  but  reinfection  from  the  mouth  prolongs 
the  process.  If  on  the  other  hand  the  opening  through  the  socket  is  plugged 
between  treatments  to  prevent  infection,  retention  of  the  secretions  has  the 


ANATOMY  AND  SLM^dERY  OF  NOSE  AND  EAR  31 

same  disach-antage  as  in  tlie  case  cjf  constant  drainage  hut  reinfection  ironi 
the  mouth. 

With  involvement  of  the  spiienoidal  sinus,  a  cannula  with  the  lip  slightly 
bent  is  passed  upward  and  hackward,  at  an  angle  (if  45  degrees  with  the 
floor  of  the  nose  through  the  ostium  into  the  sinus  itself.  The  ostium  is  at 
times  located  a  little  distance  out  from  the  septum.  This  is  medicated  and 
irrigated  as  in  the  case  of  the  other  sinuses  but  should  be  followed  by  air 
pressure  with  the  head  bent  forward  and  low  down  and  sucti(jn  carried  out 
in  the  same  posture. 

If  introduction  of  the  cannula  into  the  frontal  sinus  is  unsuccessful 
owing  to  the  fact  that  the  nasofrontal  duct  does  not  directly  communicate 
with  the  meatus  but  opens  intu  an  ethmoidal  cell,  a  passage  is  made  by 
removing  the  upper  and  anterior  portion  of  the  middle  turljinal  and  contiguous 
ethmoidal  cells,  until  a  sufficiently  large  opening  is  made  to  introduce  a  can- 
nula and  to  give  sufficient  drainage. 

When  the  ostium  of  the  maxillary  antrum  is  inaccessible  for  irrigation  or 
insufficienth'  open  for  jiroper  drainage,  an  artificial  opening  is  made  about 
half  way  back  tbnmgh  the  lateral  wall  of  the  nose  as  close  to  the  floor  as 
possible.  A  trocar  one  half  centimeter  in  thickness,  with  the  tip  three  and  a 
half  centimeters  long  bent  at  right  angles  to  the  shaft,  is  used  for  the 
purpose.  In  the  middle  of  the  lateral  wall  the  mucous  membrane  and  the 
parchmentlike  bone  can  lie  ])ierce(l  readil)'.  The  part  is  cocainized,  the  in- 
strument is  introduced  perpendicularly,  and  dien  so  turned  that  the  point 
impinges  on  the  lateral  wall.  Pressure  is  now  made  outward  and  as  the 
handle  is  moved  upward  and  downward  a  good-sized  opening  is  effected  with 
the  least  degree  of  pain.  Through  this  opening  the  cannula  is  now  introduced 
and  treatment  is  given  as  before  described.  Medication  and  irrigation  are 
repeated  f(3r  a  numter  of  sittings,  the  cavity  draining  between  times;  or  the 
patient  is  instructed  to  resort  to  irrigations  at  home,  introducing  the  cannula 
himself. 

If  the  opening  cannot  be  kept  patent  sufficiently  long  to  effect  a  cure 
— as  it  usuallv  heals  up  within  two  weeks — more  of  the  wall  can  be  removed 
by  means  of  a  forceps  or  with  an  instrument  having  the  same  curve  as  the 
trocar,  but  with  a  fraiselike  end,  which  with  a  similar  movement  will  break 
up  and  carry  away  a  greater  amount  of  bone  and  produce  a  more  permanent 
opening. 

If  the  ostium  of  the  sphenoidal  sinus  cannot  be  reached,  a  portion  of 
the  middle  turbinal  must  be  removed  to  make  it  accessible.     If  the  ostium 


32  ANATOMY  AND  SURCiERY  OF  NOSE  AND  EAR 

is  too  small  \<>v  the  introduclion  of  a  cannula  and  for  proper  drainage,  a 
portion  of  the  entire  anterior  wall  below  the  ostium  must  be  removed  with  a 
drill,  chisel,  or  bone-biting  forceps. 

Onlv  when  the  various  stages  of  this  more  conservative  treatment  have 
been  found  insufficient  to  effect  a  cure  are  more  radical  methods,  with  the 
exposure  of  the  sinuses  from  without,  permissible. 


Ill 

A  CONTRIBUTION  TO  THE  ANATOMY  AND  SURGERY  OF  THE 
NOSE  AND  ITS  SINUSES 


in 

A  CONTRIBUTION  TO  THE  ANATOMY  AND   SURGERY  OF 
THE  NOSE  AND  ITS  SINUSES 

The  specimens  of  skulls  herein  illustrated  were  olitained  during  the  course 
of  instruction  on  the  cadaver  at  the  College  of  Ph)'sicians  and  Surgeons  and 
were  prepared,  after  operative  procedure  on  them,  hy  the  students,  had  demon- 
strated  that   they   presented    points    of    special   interest. 

The  specimen  of  the  sagittal  section  showing  the  occasional  course  of  the 
infundibulum  ending  in  ethmoidal  cells,  instead  of  in  the  nasofrontal  duct,  was 
of  further  interest  on  account  of  the  single  sphenoidal  sinus.  The  series  of 
vertical  sections  presents  the  average  condition  found  in  most  human  beings ; 
so  also  the  horizontal  section,  excepting  that  in  this  one  a  marked  erosion  of 
the  left  temporal  bone  was  found  but  not  commented  upon  in  this  treatise. 


^5 


i'lalc  \'J  represents  a  skull  with  well-hjrnied  s_\niiiietrical  sinuses.  The 
frontal  sinuses  are  exposed  and  of  medium  size.  The  maxillary  antra  are 
well  developed.  A  portion  of  the  outer  wall  of  the  right  orbit  has  been 
removed;  on  the  inner  wall  the  bone  has  been  elevated  from  the  anterior 
and  posterior  ethmoid  cells,  showing  that  the  uppermost  cells  are  on  a  line 
with  the  inner  canthus  of  the  eye.  A  cannula  has  been  passed  through  the 
nasofrontal  duct  and  projects  into  the  right  frontal  sinus;  the  nasofrontal 
ducts  are  seen  to  be  located  about  one  centimeter  from  the  median  line  of 
the  face.  Their  upper  ends  also  correspond  to  the  inner  canthus  of  the  eye. 
The  ostium  of  the  right  maxillary  antrum  shows  at  the  upper  part  of  the 
inner  wall ;  a  ridge  of  Ixjne,  in  the  middle  of  the  upper  wall,  indicates  the 
infraorbital  canal.  The  floor  of  the  antrum  is  lower  than  the  floor  of  the 
nose  and  shows  the  prominences  of  sockets  of  the  molar  and  bicuspid  teeth. 
An  opening  through  the  last  molar  socket,  therefore,  corresponds  to  the  most 
dependent  point  of  the  antrum.  On  the  other  hand,  a  trocar  introduced  low 
down  and  through  the  inferior  meatus  corresponds  to  a  point  at  least  one 
centimeter  above  the  floor  of  the  antrum.  Nevertheless,  draining  an  antrum 
from  the  floor  into  the  mouth  has  great  disadvantages,  because  of  liability 
to  reinfection  from  the  mouth.  If  a  plug  is  introduced  to  prevent  reinfection, 
the  secretions  are  retained  and  the  ad\-antages  of  drainage  at  the  most  de- 
pendent point  are  lost.  \\'ith  the  intranasal  opening  and  treatment  de- 
scribed in  Chapter  II  this  disad\antage  does  not  exist,  but  repeated  cleansing 
is  possible  as  in  the  former  instance,  and  the  opening  can  be  made  the  most 
dependent  point  if  the  patient  reclines  or  sits  with  the  head  far  over  to  the 
opposite  side. 


36 


PEC 


AEC 


NFD 


OM  A 


O  F,  Optic  foramen. 

PEC.  Posterior  ethmoid  cells. 

AEC,  Anterior  ethmoid  cells. 

O  M  A,  Ostium  of  maxillary  antrum. 

NFD,  Nasofrontal  duct. 

S,  Prominences  corresponding  to  sockets  of  bicuspid  and  molar  teeth. 

C,  Cannula  passed  through  infundil)ulum  and  nasofrontal  duct  into  frontal  sinus. 


37 


Plate  \'II  demonstrates  tlie  asymmetry  of  the  frontal  sinuses,  which  is 
a  very  common  condition.  Perfect  symmetry  is  a  great  rarity.  In  this  in- 
stance a  large  sinus  with  the  outlet  into  the  left  nares  extends  far  over  to 
the  right  with  the  small  partial  septum  at  the  upper  portion,  in  the  middle 
line.  On  the  right  side  is  a  frontal  cell  representing  a  greatly  diminished 
right  frontal  sinus.  Ethmoid  cells  and  sphenoidal  sinuses  are  partially  ex- 
posed. Here  the  surgeon  would  be  able  to  introduce  the  probe  only  a  very 
short  distance  into  the  sinus  of  the  right  side,  as  described  in  Chapter  II. 
On  the  other  hand,  if  exposure  of  the  sinus  had  been  made  at  or  above  the 
supraorliital  arch.  onl\-  the  sinus  of  the  left  side  would  ha\e  been  reached  and 
that  of  the  right,  prol)ably,  missed. 


38 


PLATE    VII 


39 


Plate  VIII  shows  a  specimen  with  all  the  sinuses  exposed.  This  typifies 
a  frequent  finding  of  asymmetry  which  is  found  also  in  the  rest  of  the  head, 
the  cross  sections  frequently  showing  that  one  part  of  the  middle  or  inner 
ear  is  one  to  two  centimeters  farther  forward  or  backward  on  the  other  side. 
This  same  rule  hnlds  good  for  the  trunk  and  the  extremities.  It  may  be 
stated  as  a  corollary  in  human  anatomy  that  asymmetry  is  the  rule,  and  that 
perfect  symmetry  the  exception.  The  sinus  with  an  opening  into  the  right 
nares  is  of  medium  size  but  extends  to  the  left  of  the  median  line  of  the  face 
to  practically  correspond  to  the  sinuses  of  both  sides.  The  sinus  with  the 
opening  into  the  left  nares  represents  only  a  frontal  cell.  As  if  to  counter- 
balance the  enlarged  frontal  sinus  on  the  right  side,  nature  provided  a  cor- 
respondingly large  sphenoidal  sinus  on  the  left  side.  The  septum  separating 
the  smaller  right  from  the  larger  left  sphenoidal  sinus  has  an  important  bear- 
ing on  the  exposure  of  the  pituitary  gland,  which  is  lodged  in  the  sella  turcica. 
The  prominence  on  the  posterior  wall  of  the  sphenoidal  sinus  represents  the 
corresponding  depression  of  the  sella,  but  in  order  to  expose  the  gland,  this 
prominence,  irrespective  of  the  direction  or  deflection  of  the  sphenoidal  sep- 
tum, should  be  opened  in  the  median  line  of  the  skull.  This  specimen  also 
shows  asymmetry  of  the  maxillary  antra,  the  one  on  the  right  side  being 
larger  than  that  on  the  left. 


40 


PLATE    VIII 


41 


Plate  IX  shows  the  skull  of  a  syphilitic  subject  showing  small  frontal 
sinuses.  This  demonstrates  the  importance  of  beginning  the  incision  for 
exposure  of  the  sinus  low  down  at  the  inner  canthus  of  the  eye.  On  this 
anatomical  subject  the  student  had  made  an  incision  horizontally  through 
the  eyebrow,  and,  laefore  exposing  the  sinus,  had  penetrated  into  the  cranial 
cavity.  On  the  left  side  a  similar  incision  was  made,  and  before  the  student 
realized  he  had  entered  a  shallow  sinus,  he  penetrated  the  posterior  wall  and 
entered  the  cranial  cavity  a  second  time.  This  might  have  been  avoided 
in  both  instances  by  first  exposing  the  nasofrontal  duct  low  down  and  probing 
the  sinus  to  determine  its  size  and  location.  There  was  complete  syphilitic 
erosion  of  the  interior  of  the  nose  including  the  septum,  both  lateral  walls 
with  their  turbinals,  and  even  the  outer  wall  of  the  right  antrum.  The 
ethmoidal  cells  and  sphenoidal  sinuses  were  deprived  of  their  inferior  walls 
and  the  erosion  extended  into  the  basilar  process  of  the  occipital  bone.  The 
hard  palate  was  affected  similarly.  This  syphilitic  erosion  was  so  complete 
that  the  most  thorough  surgical  procedure  would  not  have  surpassed  it  in 
extensiveness. 


PLATE    IX 


43 


Plate  X  shows  complete  exposure  of  the  frontal  sinuses  and  a  vertical 
section  thmutih  tlic  anterior  nares.  This  specimen  was  interestins^  Ijecause 
of  the  extraordinary  depth  of  the  sinuses,  the  unusual  height  of  the  right 
sinus  in  the  median  line  and  its  extension,  particularly  over  the  right  eye, 
laterally  and  posteriorly.  The  large  dimensions  in  three  directions  made  a 
very  commodious  cavity.  The  septum  separating  the  sinuses  deviates  toward 
the  left.  The  openings  of  the  nasofrontal  ducts  are  about  one  centimeter  from 
the  median  line  and  more  than  one  centimeter  posterior  to  the  anterior  wall. 
An  incomplete  secondary  septum  is  seen  well  over  the  right  eye ;  the  portion 
of  the  sinus  to  the  outer  side  of  it  passes  far  backward  over  the  orbit,  com- 
municating with  the  other  compartment  of  the  sinus  near  the  nasofrontal 
opening.  The  nasal  septum  is  irregularly  shaped  with  a  spur  formation  on 
the  right  side  below  and  a  deflection  to  the  left  side  at  the  center.  In  both 
nares  are  seen  the  middle  and  inferior  turbinals.  The  interior  of  the  nose 
presented  nothing  uncommon. 


44 


PLATE    X 


45 


PLATE    XI 


CE 


s  s 


PG 


PEC 


Ate 


iN  F  I ) 


I"  A,  Cardti'l  artcrv . 

R  G,  Rosenmueller's  groove. 

C  E  T,  Cartilage  of  E!ustachian  tube. 

S  S,  Sphenoidal  sinus. 

P  G,  Pituitary  glanil. 

P  E  C,  Posterior  ethmoid  cells. 


A  I-'  C,  Anterior  ethmoid  cells. 

N  F  D,  Nasofrontal  duct. 

M  T,  Attachment  for  middle  turbinal. 

I  T.  Portion  of  inferior  turbinal. 

E  O,  Eustachian  orifice. 

C,   Cannula   in   infundilnilum. 


46 


Plate  XI  is  a  sagittal  section  to  the  left  of  the  nasal  septum  showing 
the  inferior  turbinal  partially  cut  away  and  the  middle  and  superior  turbinals 
removed,  exposing  the  left  frontal  sinus,  anterior  and  posterior  ethmoidal 
cells  and  sphenoidal  sinus.  A  probe  cannula  is  seen  in  the  infundibulum,  the 
upward  extension  of  which  ends  in  the  anterior  ethmoidal  cells.  In  this 
specimen,  as  is  frequent!}-  the  case,  the  frontal  sinus  and  nasofrontal  duct 
do  not  communicate  directly  with  the  iufundiljulum.  In  such  a  case  it  is 
impossible  to  introduce  a  probe  into  the  sinus  without  making  an  artificial 
opening  by  destruction  of  some  of  the  ethmoidal  cells  or  their  incomplete 
septa.  Above  the  sphenoidal  sinus  is  seen  the  pituitary  gland  with  the  dorsum 
sella  posteriorly.  Directly  behind  the  sphenoidal  sinus  lies  the  carotid  artery 
in  its  tortuous  course.  Piclow,  the  cartilage  of  the  opening  of  the  Eustachian 
tube  has  been  parth'  cut  through.     The  Eustachian  orifice  is  anterior  to  it. 


47 


Plate  XII  represents  tlie  same  section  as  the  previous  plate  and  shows 
the  part  lifted  from  the  previous  specimen.  The  section  is  still  on  the  left 
side  of  the  nasal  septum  and  shows  the  portion  of  the  middle  turbinal  which 
was  raised  from  the  previous  specimen  and  demonstrates  anterior  and  pos- 
terior ethmoidal  cells  and  the  sphenoidal  sinus.  An  arrow  indicates  the  open- 
ing of  the  posterior  ethmoidal  cell,  and  a  probe  cannula  is  introduced  through 
the  ostium  of  the  sphenoidal  sinus.  The  specimen  contains  but  one  especially 
large  sphenoidal  sinus  without  a  septum  and  with  but  one  ostium  opening 
to  the  left  side  of  the  nasal  septum.  The  tortuous  course  of  the  carotid  canal 
is  seen  directly  posterior  to  the  sinus.  -\l)o\-e  and  behind  it  is  a  section  of 
the  pituitary  gland  and  of  the  optic  chiasm.  In  the  depth,  posterior  to  the 
nasal  septum,  is  the  oritice  of  the  right  Eustachian  tube.  The  specimen 
demonstrates  the  rule  for  probing  the  sphenoidal  sinus,  namely,  that  a  probe 
or  cannula  directed  upward  and  backward  at  an  angle  of  45  degrees  with  the 
floor  of  the  nose  can  be  introduced  through  the  ostium  of  the  sinus.  Fre- 
i[uentl\'  the  ostium  is  located  a  short  distance  (%  to  y2  cm. )  laterallv  to  the 
septum,  and  this  necessitates  bending  the  tip  of  the  probe,  which  will  then 
more  readilv  find  the  opening  when  it  is  invisible,  .\fter  medicating  and 
douching  the  sinus  it  is  advisable  to  force  air  into  the  sinus  to  remove  all 
the  fluid  and  secretions  and  to  perform  suction  with  the  head  bent  well 
forward  so  that  the  ostium  is  at  the  most  dependent  point. 


PLATE    XII 


p  !•:  c— s  M 


MT 


N  S 


EO 


O  C  D  G 


C  A 


RG 


M  T,  Portion  of  middle  turljinal. 
N  S,  Nasal  septum. 
E  O,  Eustachian  orifice. 

PEC — S  M,  Arrow   passing   from   posterior  ethmoid   cell  to   superior  meatus. 
O  C  D  G,  Optic  chiasm  and  pituitary  gland. 
C  A,  Carotid  artery. 
R  G,  Rosenmueller's  groove. 


49 


PLATE    XIII 


L  FS 


R  S 


DM 


X  b 


LPS,  Left  frontal  sinus. 

R  S,  Recesses  of  sinus  separated  by  partial  septa. 

D  M,  Dura  mater. 

N  S,  Xasal  septum. 


50 


Plate  XIII  represents  a  vertical  section  through  the  frontal  bone  including 
the  nose,  viewed  from  behind.  Above,  portions  of  the  dura  mater  lining  the 
anterior  wall  of  the  cranial  cavity;  below  it  and  spreading  laterally  over  both 
eyes,  portions  of  the  frontal  sinuses  with  the  septum  dividing  them  displaced 
somewhat  to  the  right  of  the  nasal  septum.  There  are  secondary  septa  in 
each  sinus.     Below  is  the  nasal  septum  with  symmetrical  nares. 


Plate  XIV  is  a  specimen  representing  the  posterior  aspect  of  the  preceding 
plate  (Plate  XIII).  Above,  the  cranial  cavit)^  has  been  exposed.  Below  this, 
two  large  frontal  sinuses  extend  far  over  both  orbits,  showing  elevations 
and  secondary  septa.  The  septum  between  the  right  and  left  frontal  sinuses 
is  to  the  right  of  tlie  median  line.  The  ostia  of  the  sinuses  are  located  about 
one  centimeter  from  the  median  line.  The  one  on  the  right  is  low  near  the 
most  dependent  point  of  the  sinus.  The  one  on  the  left  side  is  one  centimeter 
above  the  most  dependent  point.  In  inflammatory  processes  in  the  latter,  the 
secretions  would  be  retained  irrespective  of  posture  and  most  probably  would 
necessitate  an  external  operation.  Below  is  seen  a  well-formed  septum, 
the  middle  and  lower  turbinals  showing  on  both  sides.  A  portion  of  the 
nasolachrymal  duct  has  been  exposed  on  either  side. 


PLATE    XIV 


OR  I 


N  L  D 


)  LFS 


«!  N  S 


I  T 


( )  K  F  S,  Osliuin  of  right  frontal  sinus. 

M  T,  Middle  turbinal." 

N  L  D,  Nasolachrymal  duct. 

O  L  F  S.  Ostium  of  left  frontal  sinus. 

N  S.  Nasal  septum. 

T  T,  Inferior  turbirial. 

53 


PLATE    XV 


A  EC 


M  A 


X  S 


A  E  C,  Anterior  etlininiil  cells. 

M  A,  Maxillary  antrum. 

IT,  Inferior  tiirbinal. 

I,  Infundibulum. 

M  T,  Middle  turbinal. 

O  N  L  D,  Orifice  of  nasolachrymal  duct. 

S  N  S,  Spur  formation  on  nasal  septum. 


54 


Plate  XV  represents  a  vertical  section  about  one  centimeter  posterior  to 
the  previous  one  (  Plate  XIII ),  as  seen  from  liehind.  PjcIow  tlie  cerebral  cavity 
are  seen  the  middle  turliinals  and  anterior  ethmoidal  cells.  In  both  nares  the 
uncinate  process  forms  the  groove  or  infundibuhim  which  in  this  specimen 
was  continuous  with  the  nasofrontal  duct.  Below  this  is  seen  the  inferior 
turbinal  sheltering  the  lower  opening  of  the  nasolachrymal  duct.  External 
to  the  lateral  walls  of  the  nose  are  the  beginning  of  the  maxillary  antra  on 
either  side.    The  nasal  septum  shows  a  spur  forniation  near  its  lower  end. 


55 


Plate  XVI  represents  the  same  section  as  Plate  XV,  seen  from  in  front. 
Below  the  cranial  cavity  are  the  ethmoidal  cells  reaching  high  up  on  the 
orbital  wall.  To  the  outer  side  of  the  middle  turbinals  are  the  uncinate 
processes  forming  the  infundilmli.  The  right  side  shows  a  cross  section  of 
the  ostium  of  the  maxillary  antrum  opening  into  the  infundibulum.  Lower 
down  the  inferior  turljinals  and  laterally  the  maxillary  antrum  are  seen. 
The  upper  two-thirds  of  the  nasal  septum  is  deflected  to  the  left. 


56 


PLATE    XVI 


MT 


M  A 


N  S 


\  E  C 


M  '[.  MuUlle   UirbuKil. 

M  A,  Maxillary  antrum. 

N  S,  Nasal  septum. 

A  E  C,  Anterior  ethmoid  cells. 

I,  Infundibulura. 

I  T,  Inferior  turbinal. 

57 


PLATE   XVII 


O  A  E  C— M  M 


UP 


MT 


A  !■;  c 


OM  A 


OAEC — MM.    Arrow    jjassing    through    ostium    of    anterior 

ethmoid  cell  to  middle  meatus. 
U  P.  Uncinate  process. 
M  T,  Middle  turl.inal. 
A  E  C,  Anterior  ethmoid  cells. 

I — O  M  A,   Arrow   passing   through    infundibulum   and   emerg- 
ing at  ostium   of  maxillary   antrum. 
I  T,  Inferior  turbinal. 


58 


Plate  XVII  shows  a  third  section,  about  one  centimeter  posterior  to  the 
section  shown  in  Plate  XV.  The  depression  corresponding  to  the  cribriform 
plate  is  well  marked  and  demonstrates,  as  was  stated  in  connection  with  Plate 
VI,  that  it  corresponds  in  hei.^ht  to  tlie  inner  canthus  of  the  eye  externally 
and,  as  is  seen  in  this  specimen,  to  the  height  of  the  optic  nerve  (middle  of 
eye)  posteriorly.  In  the  nose  are  seen  the  middle  turbinals  with  well-formed 
ethmoidal  cells  presenting  distinct  ostia  on  the  right  side.  An  arrow  through 
one  of  these  ostia  indicates  its  communication  with  the  middle  meatus.  Be- 
neath the  ethmoidal  cells  on  either  side  are  the  slits  (hiatus  semilunaris) 
leading  to  the  infundibuli.  On  the  right  side  an  arrow  indicates  the  course 
of  the  infundibulum  and  emerges  at  the  ostium  of  the  maxillary  antrum. 
In  this  specimen  a  probe  introduced  from  above  in  the  frontal  sinus,  through 
the  nasofrontal  duct,  followed  the  course  of  the  infundibulum  directly  into 
the  maxillary  antrum.  This  very  readily  explains  how  primary  infection  of 
the  frontal  sinus  subsequently  leads  to  secondary  infection  of  the  maxillary 
antrum.  The  secretions  of  the  sinus  flow  through  the  nasofrontal  duct  into 
the  infundibulum,  as  into  a  gutter  emptying  into  the  antrum.  The  inferior 
turbinals  are  well  formed.  The  septum  shows  a  spur  formation  at  the 
lower  end. 


59 


Plate  X\'1II  represents  the  same  section  as  previous  plate  (Plate  XVII) 
seen  from  in  front.  In  the  cranial  cavity  is  seen  the  falx  cerebri  with  a 
cross  section  of  the  longitudinal  sinus  above  and  the  tentorium  cerebelli  be- 
low. In  the  nose  are  seen  for  the  first  time  the  superior  turbinals.  This 
section  corresponds  to  the  midpoint  of  the  nose.  On  the  right  side  a  partition 
separates  the  anterior  and  posterior  ethmoidal  cells.  On  the  left  are  seen 
openings  of  the  posterior  ethmoidal  cells.  Beneath  the  middle  and  inferior 
turbinals  are  well  formed  meatuses.  The  maxillary  antra  are  commodious 
and  are  now  posterior  to  their  ostia  and  the  infundibuli.  The  uvula  is  seen 
in  the  depth  of  the  mouth. 


60 


PLATE    XVIII 


A— P  E  V 


N  S 


IT 


\  EC 


S  T 


M  T 


A — P  L  L  ,  ranitioii  separatiiiE 

posterior  ethnioiil  cells. 
X  S,  Nasal  septum. 
I  T,  Inferior  turbinal. 
A  E  C,  Anterior  ethmoid  cell. 
S  T,  Superior  turbinal. 
M  T,  Middle  turbinal. 
6i 


anterior  and 


PLATE    XIX 


1'  EC 


S  T,  Superior  turbinal. 

H  S,  Hiatus  semilunaris. 

I  T,  Inferior  turlsinal. 

PEC,  Posterior  ethmoid  cells 

M  T.  Middle  turliinal. 


62 


Plate  XIX  shows  a  section  about  one  centimeter  posterior  to  the  section 
represented  in  Plate  XVII.  Below  the  cranial  cavity  are  the  posterior  eth- 
moidal cells.  Here  the  superior,  middle  and  inferior  turhinals  are  well  dem- 
onstrated. On  both  sides  the  hiatus  semilunaris  is  well  forward.  The  maxil- 
lary antra  show  their  greatest  height.  By  the  contracted  appearance  of  adi- 
pose tissue  around  the  optic  nerve  it  is  seen  that  the  deepest  portion  of  the 
orbit  has  been  reached. 


6? 


Plate  XX.  Below  tlie  cranial  cavity  are  the  anterior  walls  of  the 
sphenoidal  sinuses  with  their  ostia,  large  and  near  the  septum.  In  such  a 
subject  it  would  be  comparatively  easy  to  introduce  a  probe  or  probe-cannula 
according  to  directions  given  and  demunstrated  under  Plate  XII,  i.  e.,  to 
introduce  the  instrument  in  an  upward  and  backward  direction  at  an  angle 
of  45  degrees  with  the  floor  of  the  nose. 

On  the  right  side  is  the  posterior  end  of  the  superior  turbinal;  on  both 
sides  the  posterior  ends  of  the  middle  and  inferior  turbinals ;  on  the  left 
side,  in  the  depth,  is  the  orifice  of  the  Eustachian  tube;  laterally  the  posterior 
walls  of  the  maxillarv  antra. 


64 


PLATE    XX 


OSS 


EST 


N  P 


PM  A 


OSS,  Ostium  of  sphenoidal  sinus. 

EST,  End  of  superior  turbinal. 

N  P,  Nasopharynx. 

O  N,   Optic  nerve. 

E  O,  Eustachian  orifice. 

P  M  A,  Posterior  wall  of  maxillary  antrum. 

65 


PLATE    XXI 


A  1    S  S 


MT 


GG 


O  1<  ss 


A  L  S  S,  Anterior  wall  of  left  sphenoidal  sinus. 
P  M  T.  Posterior  end  of  middle  turbinal. 
G  G,  Gasserian  ganglion. 

0  R  S  S,  Ostium  of  right  sphenoidal  sinus. 

1  T,  Inferior  turbinal. 


66 


Plate  XXI  represents  a  section  about  one  centimeter  posterior  to  that 
shown  on  Plate  XIX.  The  cranial  cavity  shows  the  anterior  fossae  above, 
the  middle  fossae  below.  The  Ciasserian  ganglia  are  seen  on  either  side  of 
the  sphenoidal  sinuses ;  the  latter  are  separated  1>\'  a  well-formed  perpendicular 
septum.  The  ostia  are  well  up  on  the  anterior  wall  of  the  sinuses.  This 
demonstrates  the  necessity  of  placing  the  head  well  forward  and  downward, 
if  drainage  is  to  be  efifected  through  the  natural  openings  of  the  sphenoidal 
sinuses,  and  also  the  advisability,  in  medication  or  irrigation,  of  following  this 
with  air  pressure  or  suction  or  both.  The  nasal  fossa;  are  greatly  contracted 
and  show  the  posterior  ends  of  the  middle  and  inferior  turhinnls. 


67 


Plate  XXII  represents  the  same  section  as  Plate  XXI,  seen  from  in  front. 
Above  the  sphenoidal  sinuses  is  a  section  of  the  optic  chiasm.  The  posterior 
walls  of  the  sphenoidal  sinuses  show  irregular  indentations.  A  considerable 
thickness  of  bone  is  seen  between  the  sinuses  above  and  the  contracted  nares 
below.  In  the  middle  line  is  the  posterior  end  of  the  nasal  septum.  In  the 
depth  is  the  posterior  wall  of  the  nasophar3-nx.  On  either  side  the  orifices  of 
the  Eustachian  tube. 


68 


PLATE    XXII 


p  ss 


PN  S 


N  P 


P  S  S,  Posterior  wall  of  sphenoidal  sinus. 
P  N  S,  Posterior  end  of  nasal  septum. 
N  P,  Nasopharynx. 
O  C,  Optic  chiasm. 
E  O,  Eustachian  orifice. 
69 


PLATE    XXIII 


ro 


CA.CS 


MT 


EO 


PN  S 


I'CP 


P  G,  Pituitary  gland. 

C  A,  C  S.  Carotid  artery  and  cavernous  sinus. 

M  T,  Middle  turbinal. 

E  O,  Eustachian  orifice. 

P  N  S,  Posterior  end  of  nasal  septum. 

P  C  P,  Posterior  clinoid  process. 

G  G,  Gasserian  ganglion. 

S  S,  Openings  into  sphenoidal  sinuses. 

I  T,  Inferior  turbinal. 

70 


Plate  XXIII  represents  a  vertical  section  of  the  head  seen  from  behind, 
one  centimeter  posterior  to  section  shown  in  Plate  XXI.  In  the  cranial  cavity 
the  orbits  are  shown  as  elevations  on  the  floor  of  the  anterior  fossae.  The 
middle  fosste  are  seen  on  either  side  of  a  central  mass  which  contains  open- 
ings into  the  sphenoidal  sinuses,  the  section  having  penetrated  a  part  of  their 
posterior  walls.  Above,  the  pituitary  gland  ;  laterally,  the  carotid  arteries.  On 
the  right  side  is  seen  the  Gasserian  ganglion  and  on  the  left  the  cavernous 
sinus.  Through  the  opening  of  the  sphenoidal  sinus  on  the  left  side  is  seen 
the  ostium  of  the  left  sinus,  as  was  more  clearly  demonstrated  in  Plate  XXI. 
In  the  nose  is  seen  the  posterior  edge  of  the  nasal  septum  and  the  posterior  ends 
of  the  middle  and  inferior  turbinals.  On  the  left  side  is  a  part  of  the  orifice 
of  the  Eustachian  tube.  This  specimen  also  demonstrates  that  a  compara- 
tively small  pledget  of  gauze  or  cotton  is  required  to  occlude  the  posterior 
nares  when  it  is  desired  to  prevent  blood  from  passing  into  the  throat  during 
a  hemorrhage  or  a  nasal  operation.  To  occlude  but  one  nostril  a  pledget  the 
size  of  the  end  of  a  thumb  will  suffice. 


71 


Plate  XXIV  is  the  same  section  as  is  shown  in  the  previous  plate,  seen 
from  in  front.  In  the  cranial  cavity  the  falx  cerebri  presents  the  section  of 
the  longitudinal  sinus  above,  its  divergence  below  forming  the  tentorium 
cerebelli.  The  central  bony  mass,  which  is  a  section  through  the  sella  turcica, 
shows  the  posterior  clinoid  processes.  Centrally  a  portion  of  the  pituitary 
gland  is  seen.  Laterally  the  cavernous  sinuses,  the  carotid  arteries  and  Gas- 
serian  ganglia.  The  mucous  lining  of  a  portion  of  the  posterior  wall  of  the 
sphenoidal  sinuses  is  seen  in  the  liony  mass.  Below  this  the  posterior  wall 
of  the  nasopharynx,  and  laterally  the  orifices  of  the  Eustachian  tubes. 


ST.  JOH 
MEDICAL    I'  . 
SAHXA  MOKiCA 


PLATE    XXIV 


cs 


C  A 


P  s  s 


R  EO 


C  S,  Cavernous  sinus. 

C  A,  Carotid  artery. 

P  S  S,  Portion  of  posterior  wall  of  sphenoidal  sinus. 

R  E  O,  Right  Eustachian  orifice. 

P  C  P,  Posterior  clinoid  process. 

P  G,  Portion  of  pituitary  gland. 

B  P,  Basilar  process. 

P  N  P,  Posterior  nasopharyngeal  wall. 

73 


vc  i> 


I'G 


PN  P 


Plate  X.W  represents  a  horizontal  section  of  the  head  through  the  mid- 
dle of  the  nose  as  seen  from  below  and  shows  the  following  anatomical 
features :  In  the  middle  line  the  nasal  septum.  The  lateral  wall  of  the  nose 
shows  the  middle  meatus,  inferior  aspect  of  the  middle  turbinal,  hiatus 
semilunaris ;  and  the  openings  from  the  anterior  ethmoidal  cells.  An  arrow 
passes  through  the  hiatus  semilunaris  and  infundibulum  and  emerges  at  the 
ostium  of  the  maxillary  antrum.  Here,  as  in  previous  specimens,  it  is  seen 
that  the  ostium  is  near  the  roof  at  the  inner  superior  angle  of  the  antrum  and 
located  somewhat  anterior  to  its  middle.  Externally  is  the  roof  of  the  maxil- 
lary antrum.  Posterior  to  the  middle  turbinals  are  the  superior  turbinals,  and 
posterior  and  internal  to  these  are  the  ostia  of  the  sphenoidal  sinuses.  In 
front,  between  the  lateral  wall  of  the  nose  and  the  antrum,  is  a  section  of  the 
nasolachrvmal  duct. 


74 


PLATE    XXV 


0  M  A 


O  A  !■; 


ST 


UN 


U  N,  Uncinate  process. 

O  M  A,  Ostium  of  maxillary  antrum. 

O  A  E  C,  Ostium  of  anterior  ethmoid  cell. 

S  T,  Superior  turbinal. 

N  L  D.   Nasolachrymal  duct. 

H  S — O  M  A,  Arrow  passing  through  hiatus  semilunaris 

and  emerging  at  ostium  of  maxillary  antrum. 
M  T,  ?^Iiddle  turbinal. 
OSS,  Ostium  of  sphenoidal  sinus. 


.11) 


H  S— O  M  A 


M  -1 


o  s  .s 


75 


Plate  XXVI.  Tlie  heavy  line  u\er  the  right  eye  shows  the  beginning 
of  the  line  of  incision  for  exposure  of  the  nasofrontal  duct  and  frontal  sinus. 
The  lighter  dotted  line  over  the  right  eyebrow  represents  the  incision  for  a 
sinus  extending  far  laterally  and  is  made  continuous  with  the  first  incision. 
This  incision  is  applicable  if  the  entire  anterior  wall  of  the  sinus  is  to  be 
removed,  or  a  ledge  is  to  be  left  in  place  to  support  the  soft  parts.  On  the 
left  side  is  seen  the  incision  for  an  osteoplastic  flap  when  probing  through 
the  nasofrontal  duct  has  shown  the  sinus  to  be  a  large  one.  Marked  depres- 
sion would  result  if  the  entire  bone  were  sacrificed.  With  the  osteoplastic 
method  the  entire  periosteum  is  left  in  contact  with  the  bone;  the  bone  is 
chiseled  with  a  narrow  thin  osteotome  on  three  sides,  corresponding  to  the 
incision  line.  On  the  fourth  side,  which  forms  the  liase,  the  bone  is  nicked 
laterally  so  that  it  will  break  true  in  a  straight  line,  when  the  osteoplastic  flap 
is  pried  open  from  below.     This  should  be  done  by  a  quick  movement. 

The  dotted  incisions  starting  at  the  sides  of  the  pyriform  fossa  (bony  nasal 
aperture)  passing  upward  to  the  de])ression  at  the  root  of  the  nose  w'ith  a 
cross  cut  joining  the  incisions  on  either  side,  demonstrate  the  method  for  ex- 
posing the  interior  of  the  nose  as  given  in  Chapter  I\^. 

The  incision  on  the  left  side  at  the  junction  of  the  gum  and  upper  lip 
is  the  one  chosen  in  most  instances  for  exposure  of  the  anterior  wall  of  the 
maxillary  antrum. 

If  the  tissues  are  very  firm  and  indurated  and  do  not  permit  sufficient 
retraction  of  the  soft  parts  to  expose  the  entire  anterior  wall  of  the  antrum, 
an  incision  as  indicated  on  the  right  side,  corresponding  to  the  entire  width 
and  height  of  the  anterior  wall  of  the  antrum,  can  be  made  to  include  either 
the  soft  parts  alone  or  the  latter  with  the  bone  attached. 


76 


PLATE    XXVI 


^^^m^^' 


77 


Plate  XXVII  shows  on  the  right  side  beginning  of  the  incision  and  the 
first  stage  of  exposure  of  the  frontal  sinus.  The  soft  parts  have  been  incised 
at  the  inner  canthus  of  the  eye,  in  a  direction  upward  and  outward  through 
the  periosteum  down  to  the  bone.  A  borer,  held  in  a  direction  upward  and 
backward  about  one  centimeter  from  the  median  line,  has  penetrated  the 
bone  to  the  nasofrontal  duct.  The  probe  is  introduced  through  this  opening 
into  the  sinus  to  determine  its  location  and  dimensions.  When  the  sinus  is 
small  the  opening  is  enlarged  upward  and  laterally  with  chisel,  burr  or 
rongeur  and  thus  exposed.  When  the  sinus  is  large,  one  of  two  methods 
may  be  chosen.  With  the  first,  the  incision  is  enlarged  upward  and  out- 
ward and  the  periosteum  of  a  ledge  of  bone,  corresponding  to  the  supraorbital 
ridge,  is  left  undisturbed,  while  the  periosteum  above  and  below  the  intended 
ledge  is  incised  and  elevated  from  the  bone.  The  bone  of  the  anterior  wall  of 
the  sinus  is  now  completely  removed  above  and  below  the  ledge  in  order  to 
expose  every  niche  of  the  sinus.  If  the  condition  of  the  mucous  membrane 
warrants,  the  latter  can  now  be  removed  and  any  necrosed  bone  curetted.  If 
the  posterior  wall  of  the  sinus  is  curetted,  great  care  must  be  taken  to  avoid 
injury  to  the  dura  mater.  A  probe  is  now  passed  through  the  nasofrontal 
duct  into  the  nose  to  determine  its  course.  Thorough  drainage  is  effected  by 
enlarging  the  duct  with  burr  or  trocar,  and  tubing  is  introduced  through 
which  the  first  few  after  treatments  are  to  be  given.  The  preserved  perios- 
teum is  now  replaced,  the  external  wound  is  sutured  and  subsecjuent  treat- 
ments are  carried  out  intranasally. 


73 


PLATE    XXVII 


79 


On  the  left  side  is  shown  exposure  of  the  sinus  by  the  osteoplastic  method, 
for  which  the  indications  and  technic  were  given  in  the  description  of  the 
previous  plate.  After  the  original  incision  and  boring  of  the  bone,  the  exact 
height  and  width  of  the  very  large  sinus  must  be  determined  by  the  curved 
probe.  The  first  incision  is  carried  outward  along  the  supraorbital  ridge.  The 
second  upward  from  the  point  of  beginning,  and  the  third  vertically  upward 
from  the  end  of  the  first,  corresponding  in  height  to  its  parallel.  The  in- 
terior of  the  sinus  is  dealt  with  as  described  in  the  previous  method  and 
the  flap  is  replaced,  the  periosteum  being  sewed  first,  the  skin  suture  being 
completed  without  draining  the  cavity  other  than  intranasally. 

On  the  left  side  below  is  shown  the  interior  of  the  maxillary  antrum.  The 
parts  have  been  incised  down  to  the  bone  beginning  close  to  the  outer  border 
of  the  pyriform  fossa  and  extending  outward.  The  periosteum  has  been 
elevated  from  the  anterinr  wall  u])  to  and  on  either  side  of  the  infraorbital 
vessels  and  nerve.  Chiseling  is  now  begun  in  the  center  of  the  antral  wall 
and  gradually  enlarged  downward  to  the  alveolar  ridge  and  then  inward 
and  outward  and  eventually  upward,  great  care  being  taken  not  to  injure  the 
infraorliital  canal  and  its  structures.  The  bone  on  either  side  of  the  infra- 
orbital should  be  removed  to  the  edge  of  the  orbit.  The  antrum  is  now 
completely  exposed  and  can  be  dealt  with  accijrding  to  indications.  (See 
Plate  VI.) 

The  radical  exposure  of  the  antrum  is  warranted  only  in  chronic  condi- 
tions where  diseased  membrane,  eroded  bone,  polypi  or  growths  are  suspected. 
All  the  more  acute  and  simpler  conditions  are  treated  by  the  intranasal  method. 
If  the  lining  of  the  antrum  is  to  be  left  in  place,  a  drainage  opening  should 


80 


be  made  at  the  lower  part  of  the  inner  wall,  the  size  to  be  determined  by 
the  amount  of  secretion  it  is  necessary  to  drain.  A  small  opening  can  be 
made  by  a  trocar,  as  referred  to  in  the  article  previously  mentioned,  a  large 
one  with  a  f raise  or  bone-biting  forceps.  If  the  lining  membrane  must  be 
removed,  the  cavity  can  be  treated  in  the  following  manner :  The  mucous 
membrane  of  the  lateral  wall  (jf  the  nose  of  the  corresponding  side  is  ele- 
vated from  its  underlying  jjone,  the  inferior  turbinal  being  cut  away  at  its 
attachment  or  included  in  the  membranous  flap.  This  can  be  easily  done  by 
introducing  the  periosteal  elevator  at  the  edge  of  the  bone  on  the  side  of 
the  pyriform  fossa,  and  working  backward.  After  the  membrane  is  com- 
pletely loosened  the  inner  bony  w^all  of  the  antrum  is  removed  with  bime- 
biting  forceps  through  the  opening  made  in  the  anterior  antral  wall.  The 
membranous  wall  in  the  nose  is  now  severed  close  to  the  floor  and  brought 
into  the  antral  cavity  to  form  its  new  lining.  This  is  pressed  firmly  against 
the  bone  and  held  in  place  by  gauze  packing.  If  the  tensiim  on  the  mem- 
branous periosteal  flap  is  too  great,  vertical  incisions  should  be  made  at 
either  end. 

\\'ith  the  simpler  procedure  the  incision  through  the  gum  can  be  com- 
pletely sutured  and  the  after-treatment  is  carried  out  intranasally.  I*"(ir  the 
more  extensive  procedure  the  packing  for  holding  the  membranoperiosteal 
flap  against  the  antral  walls  can  best  be  done  through  the  original  incision  and 
the  latter  permitted  to  close  immediately  after  the  membranoperiosteal  flap 
has  become  adherent. 


8l 


Plate  XXVIII  sliows  on  the  right  side  an  osteoplastic  flap  corresponding  to 
the  incision  shown  in  Plate  XX\'I.  Tin-  soft  jnirts  have  been  incised  down 
to  the  bone,  the  periosteum  has  been  pu^lK'd  away  slightly  in  the  direction 
away  from  the  osteoplastic  flap  and  a  tiiin  narrcnv  osteotome  has  ])ierced  the 
anterior  wrdl  almut  nne-half  centimeter  to  the  outer  side  of  the  edge  of  the 
pyriform  fossa  directly  above  the  alveolar  process.  From  here  the  bony  inci- 
sion is  continued  to  a  point  close  to  the  outer  edge  of  the  superior  maxilla. 
From  the  ends  of  this  incision  the  bone  is  chiseled  upward  close  to  the  infra- 
orbital ridge.  At  the  base  of  the  flap  the  bone  has  been  nicked  on  both  sides 
and  the  traji  door  pried  ii[k-ii  troni  lielow. 

The  plate  also  depicts  the  nasal  flap  turned  down  after  the  bony  structure 
had  l)een  se\-ered  by  the  Gigli  saw  following  the  course  of  the  primary  inci- 
sion (Plate  XX\T).  The  remaining  cartilage  of  the  septum  has  been  cut 
to  permit  cnnii)lete  depression  of  the  flap.  In  the  interior  of  the  nose  is 
seen  a  septum  with  a  central  enlargement,  protruding  more  into  the  right 
nostril.  On  either  side  are  the  middle  and  inferior  turjjinals  and  in  the  left 
nares  the  lateral  wall  of  the  middle  meatus.  This  exposure  permits  partial 
or  complete  removal  of  the  entire  interior  structure  of  the  nose.  By  removing 
a  wedge-shaped  section  of  the  septum  the  anterior  wall  of  the  sphenoidal 
sinus  can  be  exposed  and  removed  without  interference  of  any  other  struc- 
ture. Also,  the  anterior  and  posterior  ethmoid  cells  or  the  ethmoids  and 
sphenoidal  sinuses  can  be  exposed  or  removed  without  interference  of  the 
frontal  sinus.  If  more  room  is  re'iuired  because  of  a  deflected  septum  on 
the  side  to  lie  operated  upon,  the  septum  can  be  severed  close  to  the  floor  of 
the  nose  and  temporarily  pushed  to  the  other  side.  If  this  does  not  suffice 
for  necessary  manipulations  in  the  depth,  the  entire  septum  may  be  removed. 
The  septum  is  severed  with  strong  curved  scissors  near  the  roof  of  the  nose, 
cutting  straight  backward  until  the  s]>henoidal  sinus  is  reached  and  then 
slantingly  downward  along  its  anterior  wall.  A  strip  of  septum  sufficient 
to  facilitate  control  of  hemorrhage  should  be  left  along  the  roof.  If  it  is. 
necessary  to  remove  the  turbinals.  this  can  be  done  with  straight  scissors. 
The  ethm(ji(l  cells  are  most  readily  opened  with  a  bone  curette.  When  the 
orbital  plate  is  reached  this  presents  a  decidedly  greater  resistance  than  the 
partition  walls  between  cells  and  serves  as  a  barrier  between  the  field  of  opera- 
tion and  the  contents  of  the  orbit.  The  same  resistance  is  met  at  the  cribri- 
form plate  and  will  thus  prevent  injur\-  to  the  dura  mater. 

82 


PLATE  XXVIll 


83 


Plate  XXIX  shows  on  the  right  side  the  exposure  of  a  large  frontal  sinus, 
above  and  l>elo\v  the  supraorbital  ridge,  a  ledge  of  bone  having  lieen  left 
behind  for  support  of  the  tissues.  Through  the  lower  opening  a  bone  curette 
was  passed  backward,  breaking  down  the  partitions  between  the  ethmoid  cells. 
Eventually,  the  sphenoidal  sinus  was  penetrated. 

By  looking  into  the  nose  it  can  be  seen  that  the  middle  turbinal  has  been 
presented  on  the  right  side.  This  procedure  is  similar  to  the  Killian  opera- 
tion. On  the  left  side  of  the  nose,  in  contrast  to  this,  removal  of  the  ethmoid 
cells  and  of  the  sphenoidal  sinus,  as  described  in  connection  with  the  previous 
plate,  is  shown  by  the  nasal  flap  method.  After  employing  the  above  two 
methods  for  removal  of  ethmoid  cells  and  sphenoidal  sinus  on  a  large  num- 
ber of  subjects,  the  latter  method,  /.  c.  In'  the  nasal  route,  has  been  found 
much  simpler  of  execution,  more  thorough  and  gives  a  far  better  oversight. 

In  this  plate  exposure  of  the  frontal  sinus  on  the  left  side  is  again  shown 
by  the  osteoplastic  flap  method  in  comparison  with  the  method  for  radical 
exposure,  as  shown  on  the  right  side. 


84 


PLAT)-,  xxrx 


85 


RESUME 
I 

INTRODUCTION 

On  retlccting  on  tlx-  anatimnV-al  and  snrgical  features  present  in  the  upper 
part  of  tlie  respiratory  tract,  /.  c.  the  nose  and  its  accessory  sinuses,  a  number 
of  important  generahzations  can  be  made  wliich  should  serve  as  guides  in 
treatment  and  operative  procedures  in  that  region. 

Inspection  of  a  skull  in  whicli  the  bone  is  sufficiently  transparent  on  the 
inner  wall  of  the  orbit,  will  shnw  that  the  anterior  and  posterior  ethmoid  cells 
extend  upward  to  a  point  on  a  line  with  the  inner  canthus  of  the  eye  (Plate 
VI).  Also,  on  looking  from  above  and  comparing  the  cribriform  plate  with 
a  landmark  on  the  face  (Plate  XI)  or  looking  into  the  nose  from  below 
(Plates  VII.  XIV,  XXVIII  and  XXIX).  and  noting  the  height  of  the  roof, 
it  will  be  seen  that  they,  too,  correspond  to  this  same  point.  Hence,  in  order 
to  avoid  penetrating  the  anterior  cerebral  fossa,  n.o  instrumentation  within 
the  nose,  posterior  to  the  nasofrontal  duct,  should  be  done  higher  than  a 
point  corresponding  to  tlie  inner  canthus  of  the  eye. 

Another  point  of  interest  is  that  asymmetry  in  the  nose  is  the  general 
rule.  Beginning  with  the  septum  it  is  found  that  in  the  majority  of  patients, 
as  well  as  in  anatomical  subjects,  there  is  a  deviation  to  one  side  or  the  other, 
or  a  projection  in  the  form  of  a  spur.  Our  attitude  toward  this  condition 
should  be  conservative,  that  is,  not  to  meditate  on  the  immediate  removal 
of  every  prominence  and  projection  simply  because  it  exists,  but  to  interfere 
onlv  when  it  is  found  that  a  bonv  obstruction  exists  which  prevents  a  suffi- 
cient volume  of  air  from  being  inhaled  through  the  nose  to  expand  the  lungs  to 
their  full  capacity,  or  when  insufficiency  on  one  or  the  other  side  influences 
the  hearing  apparatus.  Oftentimes  the  swollen  turbinal  lying  against  the 
projection  is  the  cause  of  the  obstruction,  and  with  proper  treatment  this 
will  in  due  time  assume  its  correct  proportions. 

Asymmetry  of  the  sinuses  is  well  demonstrated  by  the  specimens  shown 
in  Plates  A'll,  VIII  and  X,  the  first  of  which  presents  a  large  left  frontal 
sinus  extending  far  over  to  the  right  side ;  the  right  frontal  sinus  is  repre- 
sented by  merelv  a  frontal  cell.  Plate  \^III  shows  asymmetry  in  all  the 
accessory  sinuses,  and  a   sinus  spreading  to  both  sides  of  the  median  line 

86 


ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR  87 

and  drainiiifj  tlifdugli  a  right-sided  nasofrimtal  duct.  On  tiie  left  side  the 
nasofrontal  duct  communicates  with  a  small  frontal  cell.  In  this  specimen  it 
appears  as  though  Nature  had  endea\ored  to  counterbalance  the  parts  l)y  pro- 
viding a  small  right-sided  sphenoidal  sinus  for  the  large  frontal  sinus,  and  a 
large  sphenoidal  sinus  on  the  left  side  for  the  small  frontal  sinus  of  that 
side.     The  maxillary  antra  also  are  asymmetrical. 


II 

EXPOSURE  OF  FRONTAL  SINUS 

If  inllammation  (jf  the  frontal  sinus  cannot  he  controlled  ijy  the  conserva- 
tive measures  mentioned  in  the  article  previously  referred  to,  an  external 
operation  becomes  necessary.  This  is  the  case  also  if  the  lining  membrane  is 
chronically  affected  or  necrosis  of  the  bone  or  polypi  are  present. 

An  incision  is  made  beginning  at  the  inner  canthus  of  the  eye,  curving 
outward  and  upward  through  the  bniw  and  ending  short  of  the  supraorbital 
vessels  and  nerves  (Plate  XXVI).  The  incision  passes  through  the  perios- 
teum down  to  the  bone,  the  purpose  being  to  expose  the  nasofrontal  duct. 
According  to  Plate  \T  it  will  be  seen  that  the  duct  is  located  about  one  centi- 
meter from  the  median  line  of  the  face.  A  borer  is  placed  against  the  nasal 
bone  at  a  point  corresponding  to  the  inner  canthus  of  the  eye  and  an  opening 
large  enough  freely  to  admit  a  probe  is  made  in  a  direction  upward  and 
backward  (Plate  XXVTT),  When  the  nasofrontal  duct  has  been  reached, 
the  probe  is  introduced  into  the  sinus  to  ascertain  its  size  and  one  of  the  fol- 
lowing methods  determined  upon.  First,  the  opening  is  enlarged  both  upward 
and  outward  until  the  supraorbital  ridge  has  Iieen  reached;  with  a  small  sinus 
all  necessar\-  inspection  and  instrumentation  can  l)e  performed  through  such 
an  opening  and  mucous  membrane  as  well  as  diseased  bone  can  be  removed. 
Second,  in  the  case  of  a  larger  sinus  the  same  opening  with  another  opening 
above  the  supraorliital  ridge  should  be  made,  leaving  a  ledge  of  bone,  about 
one-third  of  a  centimeter  in  width,  corresponding  to  the  orbital  ridge,  to 
serve  as  a  support  for  the  soft  parts,  thus  avoiding  the  deformity  of  a  depres- 
sion (Plate  XXTX).  In  this  instance  the  skin  should  be  dissected  up,  but 
the  periosteum  corrcspduding  to  the  ridge  is  left  intact.  Above  the  ridge 
the  periosteum  should  be  elevated  and  pushed  upward  as  far  as  is  necessary 
for  the  removal  of  the  bone. 


88  ANATOMY  AND  SL-RGERY  OF  NOSE  AND  EAR 

Third,  for  very  large  sinuses  an  osteoplastic  flap  can  be  formed  by  cutting 
the  soft  parts  and  chiseling  the  bone  along  the  supraorbital  arch,  and  making 
two  perpendicular  incisions  from  either  end  of  this  curved  incision,  the  base 
of  the  tlap  being  above  (Plates  NNVT,  XNVH  ami  XXIX).  The  exact  size 
must  lie  determined  b\-  means  of  a  ])rijlie  intr(.)duced  through  the  original  inci- 
sion exposing  the  nasofrontal  duct.  The  plate  of  bone  is  raised  by  means 
of  an  elevator  or  by  any  other  firm  instrument,  and  can  be  made  to  break 
more  readily  by  nicking  the  Ixnie  on  either  side  at  the  base  line.  After  the 
interior  is  inspected  the  diseased  nienil)rane  or  pohpi  are  removed  or  the 
necrosed  bone  is  curetted,  and  the  natural  opening  of  the  nasofrontal  duct  can 
be  widened  by  introduction,  in  a  direction  downward  and  backward,  of  a  trocar 
of  any  desirable  size.  ^V  thick  trocar  will  tear  the  mucous  membrane  of  the 
canal  as  well  as  crush  the  partitions  of  the  anterior  ethmoid  cells.  Subsequent 
drainage  is  efi:'ected  intrruiasally.  The  osteoplastic  flap  is  turned  down  into 
place  and  pressed  firml\-  to  produce  good  adjustment  of  the  bony  edges.  The 
periosteum  and  deeper  tissues  are  sutured  first,  and  suturing  of  the  skin  is 
completed  without  an)-  opening  for  draining  the  sinus,  but  due  regard  must 
be  given  to  drainage  in  case  of  jnirulent  intlammation  which  might  have 
occurred  in  the  tissues  exterrial  to  the  sinus  or  bone. 


Ill 

EXPOSURE   OF    M.\XILL.\RY    -VXTRUM 

If  an  inflammation  of  the  maxillary  antrum  is  not  amenable  to  intranasal 
treatment  as  described  in  the  previously  mentioned  article,  owing  to  perma- 
nently chronicalh'  altered  mucous  membrane,  polypi  or  necrosed  Ijone,  the 
radical  exposure  should  consist  in  the  removal  of  the  anterior  wall  of  the 
antrum  by  an  incision  through  the  alveolar-labial  cleft  (Plate  XXVI).  The 
incision  passes  through  the  soft  parts  down  to  the  bone,  the  periosteum  being 
elevated  to  the  point  near  the  infraorbital  canal,  care  being  taken  to  avoid 
injurv  io  the  infraorbital  vessels  and  nerves  (  Plate  XXMI  I.  With  a  chisel, 
borer  or  l)urr  the  niid])(_iint  of  the  anterior  wall  is  opened  and  extended  in  all 
directions,  especially  below,  internally  and  externally.  On  account  of  the 
infraorbital  canal,  caution  is  necessary  in  approaching  the  upper  part  (Plate 
VI).  Diseased  membrane,  polypi  or  necrosed  bone  can  now  be  dealt  with  as 
necessary,  and  completely  extirpated.  For  drainage  a  sufficiently  large  open- 
ing can  now  be  made  into  the  nose,  preferal)ly  near  the  floor,  but  if  the  antrum 


ANx\TO]\n'   AND  SrUCKRY  OF  NOSE  AND  EAR  89 

has  been  denuded  cif  nienilirane  ur  a  lart^e  cnnununicatidH  is  desired,  tlie  enlire 
inner  hony  wall  nt  the  antiaini  can  lie  removed  and  the  nasal  niueous  mem- 
brane can  be  eut  intu  llaps  with  their  attachment  above,  the  inferior  turbinal 
being  included  in  the  llap  or  removed  and  the  membrane  applied  to  the 
denuded  walls  of  the  antrum  as  described  under  Plate  XXVII.  In  tliis  way 
healing  will  be  hastened.  Intranasal  drainage  is  preferaljle  in  every  instance 
except  when  nasal  membrane  is  to  be  used  to  line  the  antrum,  in  which  case 
repacking  of  the  cavity  can  be  accomplished  through  the  anterior  wall. 

If  desirable  to  carry  out  the  flap  method  as  described  under  plates  XXVI 
and  XXVIII  the  tissues  are  incised  to  form  a  flap  with  its  base  above  and 
including  the  entire  anterior  wall  of  the  antrum. 

After  chiseling  the  bone  on  three  sides,  corresponding  to  the  limits  of 
the  anterior  w^all  of  the  antrum,  the  base  line  is  nicked  on  either  side  and 
the  bony  plate  pried  open  from  below,  with  due  care  not  to  lacerate  the  ves- 
sels and  nerve  at  the  infr,-i(ir])ital  canal.  After  treating  the  interior  of  the 
antriuu  liy  one  or  the  other  method  as  suggested  above,  the  trap  door  is 
brought  back  into  place.  If  the  bone  is  involved  and  requires  removal,  this 
can  now  be  done;  if  it  is  to  jje  retained  the  osteoplastic  flap  is  returned  to  its 
original  position,  the  periosteum  and  deeper  tissues  sewed  first  and  then  the 
skin.  If  subsequent  drainage  and  ])acking  should  be  required,  this  can  be 
accomplished  by  an  opening  into  the  mouth  through  the  aheolar-labial  cleft. 

IV 

EXPOSURE  OF  ETHMolU.\L   CELLS   AND  SPHENOIDAL   SINUSES 

The  location  of  the  anterior  and  posterior  ethmoidal  cells  and  the  sphe- 
noidal sinuses  is  such  that  opening  or  removal  of  them  is  possible  by  intra- 
nasal operation. 

The  introduction  of  a  probe  cannula  into  the  openings  of  anterior  and 
posterior  ethmoidal  cells  is  practically  impossible,  owing  to  the  labyrinthian 
nature  of  their  arrangeiuent. 

On  the  other  hand,  the  opening  of  the  sphenoidal  sinus  can  often  be 
seen,  but  even  if  not  seen  it  can  be  reached  with  a  probe  or  probe-cannula 
by  directing  the  latter  upward  and  liackward  at  an  angle  of  45  degrees  with 
the  floor  of  the  nose.  If  the  opening  is  some  distance  from  the  middle  line, 
the  end  of  the  instrument  should  be  slightly  bent.  When  introduced  in  the 
direction  stated,  the  end  of  the  instrument  will  find  the  ostium  by  a  turning 
movement. 


90  ANATOMY  AND  SURCiERV  OK  NOSE  AND  EAR 

The  ethmoidal  cells  and  sphenoidal  sinus  also  can  be  reached  through  the 
incision  for  exposing  the  frontal  sinus,  and  with  due  consideration  to  their 
external  landmarks,  as  reiterated  on  the  foregoing  pages,  can  be  made  part 
of  that  exposure. 

A  third  method  of  reaching  the  ethmoids  and  sphenoidal  sinus  is  by  the 
osteoplastic  flap  method  of  the  nose  described  more  fully  further  on.  The 
advantage  of  tlie  preceding  method  is  that  it  leaves  the  turbinated  bones  intact, 
even  though  the  ethmoid  cells  are  ccjmpietely  eliminated,  and  the  operation  can 
be  made  part  of  the  frontal  sinus  exposure  if  that  has  become  necessary.  If 
the  latter  is  not  the  case,  the  osteoplastic  flap  method  of  the  nose  is  far  more 
advantageous  for  very  complete  removal  of  the  lateral  masses  and  exposure  of 
the  sphenoidal  sinuses,  and  the  view  gained  thereby  is  greater  than  by  any 
other  procedure. 

V 

EXPOSURE  OF  INTERIOR  OF  NOSE 

As  already  stated,  with  the  examination  of  a  great  number  of  skulls  and 
comparison  of  the  deeper  structures  with  the  landmarks  on  the  face,  it  is 
found  that  the  height  of  the  cribriform  plate  and  the  uppermost  ethmoidal 
cells  correspond  practically  to  the  inner  canthus  of  the  eye;  so  that  if  the 
interior  of  the  nose  is  exposed  to  this  height,  this  level  is  the  highest  required 
for  intranasal  operations. 

Hence  in  the  case  of  extensi\e  removal  of  the  entire  labyrinth  and  the 
sphenoidal  sinus,  or  for  removal  of  a  tumor  involving  those  parts,  the  best 
exposure  can  be  obtained  with  the  osteoplastic  flap  metlKjd,  and  interference 
with  the  frontal  sinus  or  maxillary  antrum  becomes  entirely  unnecessary. 

To  expose  the  nose  from  in  front,  the  simplest  procedure  and  one  that 
gives  the  best  view  is  as  follows :  The  first  step  is  a  transverse  incision  over 
the  root  of  the  nose.  An  incision  is  then  made  from  the  root  downward  on 
either  side  of  the  nose  to  the  angle  of  the  pyriform  fossa.  The  tissues  are 
cut  directlv  through  the  periosteum  to  the  bone.  The  soft  parts  to  the  outer 
side  of  these  incisions  are  pushed  back  sufficiently  to  make  way  for  the  Gigli 
wire  saw.  The  bone  at  the  root  of  the  nose  is  now  sawed  until  a  sufficient 
hold  is  ac(|uire(l  to  continue  the  saw  cut  downward,  corresponding  to  the 
incisions  on  either  side  until  the  angles  of  the  pyriform  fossa  have  been 
reached.     On  elevating  the  nose  by  raising  the  flap  at  the  root  (the  patient 


ANATOMY  AND  SIRCI'IKN'  OF  NOSE  AND  EAR  91 

being  in  a  prone  position),  the  lower  part  of  the  septum  will  offer  some  re- 
sistance. The  detached  portion  is  then  drawn  downward,  and  if  a  complete  de- 
pression of  the  loosened  parts  has  nut  heen  effected,  the  cartiluL^e  of  the 
septum  which  still  remains  can  he  incised  until  com[)lete  downward  lolding  of 
the  nose  is  secured.  The  ahe  and  the  columna  form  the  hinge  on  which 
it  can  he  hent.  (  Plates  X.WT  and  XXVTII.)  The  exposure  thus  effected 
corresponds  practically  to  the  full  lieight  and  width  of  the  nose  and  permits 
complete  reposition  without  loss  of  tissue  other  than  the  minute  line  oi  bone 
through  which  the  wire  saw  jjasses.  With  daylight,  lamp  and  head  mirror, 
electric  head  light  or  a  small  electric  pencil,  4-5  inches  long,  which  can  be 
introduced  on  the  side  of  the  septum  for  direct  illumination  or  on  the  op- 
posite side  for  transillumination,  the  entire  nasal  cavity  can  be  inspected.  If 
the  septum  deviates  to  one  side  and  the  smaller  cavity  is  to  be  operated  upon, 
the  septum  can  be  cut  with  scissors  from  before  backward,  close  to  the  floor 
of  the  nose  and  released  in  its  full  length ;  the  entire  septum  can  thus  be 
pushed  to  the  opposite  side,  giving  ready  access  to  the  side  to  be  operated  upon. 
When  this  more  radical  pr(.)cedure  is  unwarranted,  suilicient  space  can  be  ob- 
tained by  removing  the  dexiatcd  pcirtinn  of  the  cartilagin(.)us  and  liony  sejitum 
lying  between  the  two  layers  of  the  septal  membrane.  In  septal  involvement 
by  a  new  growth,  the  septum  can  readily  be  removed  in  toto  by  severing  its 
attachment  above  and  below  with  curved  scissors.  The  curved  instrument 
is  particularly  applicable  for  the  reason  that  the  posterior  portion  of  the 
septum  corresponds  to  the  slojie  of  the  sphenoidal  sinus  which  forms  the  upper 
half  of  the  nasal  wall  posteriorly,  the  lower  half  corresponding  to  the  naso- 
pharynx. 

The  view  obtained  with  the  exposure  mentioned  above  shows  the  follow- 
ing important  features  on  both  sides :  In  the  middle  line  the  nasal  septum, 
either  straight  or.  as  in  most  cases,  slightly  deviated  in  its  upper  or  lower 
portion  or  both  upper  and  lower  portions,  with  or  without  spur  formation. 
Laterally,  above,  the  space  between  the  middle  turbinate  bone  and  the  septum 
extends  to  the  roof  of  the  nose,  which  is  formed  by  the  cribiform  plate  of 
the  ethmoid.  Further  down  is  seen  the  fold  or  Ijridge  formed  by  the  anterior 
portion  of  the  middle  turbinal,  which  serves  as  a  guide  for  introduction  of 
instruments  into  the  nasofrontal  duct.  This  fold  or  bridge  is  generally  re- 
moved by  rhinologists  who  wish  to  treat  the  frontal  sinus  intranasally.  Di- 
rectly back  of  this  fold  in  the  middle  of  the  meatus  is  the  crescentic  edge  of 
the  uncinate  process  extending  from  above  and  in  front,  downward  and  back- 
ward, which  forms  with  the  prominent  ethmoid  cell  overhanging  it,  the  slit 


ij2  ANATOMY  AND  SURGERY  OI-'  NOSE  AND  EAR 

ciIIl-iI  hiatus  st-niiluiiaris.  This  (jpcns  intw  the-  larger  space  or  channel  called 
the  intundihuluni,  fcjrnied  h\-  the  same  anatuniical  structure  as  the  hiatus,  /.  e., 
the  uncinate  process  of  the  ethmoid  below  and  the  bulla  ethmoidalis  above. 
The  ostium  of  the  maxillary  antrum  invariably  opens  into  this  channel  or 
trough  and  generally  also  the  nasofrontal  duct,  hence  it  is  the  usual  deep 
guide  for  probing  the  nasofrontal  duct  and  sinus.  In  most  instances  1  have 
found  that  with  a  long  probe-cannula  bent  into  a  semicircle  about  8  centi- 
meters in  diameter,  the  point  slightly  curved  outward,  it  is  possible  to  enter 
the  frontal  sinus  through  the  infundibulum  and  nasofrontal  duct  and  to  intro- 
duce cleansing  solutions  and  medicaments  in  sinusitis  without  removal  of  a 
portion  of  the  middle  turbinate  bone  or  any  other  operative  procedure.  In 
all  cases  of  sinusitis  it  is  well  to  try  this  mode  of  treatment  before  perform- 
ing a  more  extensive  procedure. 

Below,  the  inferior  turbinate  bone  anil  meatus  are  visible.  Posteriorly  the 
posterior  wall  of  the  nares  is  seen  to  be  made  up  in  its  upper  half  by  the 
sphenoidal  sinus,  the  anterior  wall  slanting  frijm  the  midpoint  of  the  nose 
above,  downward  and  backward,  until  it  reaches  the  deeper  recess  of  the 
nasopharynx,  which  forms  the  lower  half  of  the  posterior  wall.  At  the  upper 
part  of  the  anterior  wall  of  the  sphenoidal  sinuses  are  their  ostea.  It  can 
be  readih-  understood  that  when  infection  occurs  in  the  sinuses,  they  can 
drain  only  when  the  head  is  bent  forward  until  the  face  is  in  a  horizontal 
or  lower  position,  and  this,  too,  only  when  swelling  of  the  mucous  membrane 
does  not  occlude  the  ostia. 

To  introduce  a  probe-cannula.  the  following  procedure,  described  some- 
what more  fullv  than  heretofore,  should  be  carried  out :  Inasmuch  as  the 
ostia  are  situated  near  the  upper  part  of  the  sinuses  and  the  wall  of  the  sinus 
begins  at  about  the  midpoint  of  the  nose,  a  probe-cannula  should  be  directed 
upward  and  backward  between  the  middle  turbinal  and  the  septum  at  an 
angle  of  45  degrees  with  the  floor  of  the  nose.  If  the  (jstia  are  located  near 
the  septum  and  the  middle  turbinals  do  not  project  unduly,  this  opening 
can  be  readilv  seen  by  anterior  rhinoscopy  and  the  probe  or  cannula  intro- 
duced at  sight.  If  the  openings  are  further  to  the  side,  away  from  the 
septum  and  hidden  ])\  the  middle  turbinals,  the  instrument  must  be  slightly 
bent  at  the  end.  By  turning  the  cur\-ed  end  in  an  outward  direction  after 
it  has  reached  the  wall  of  the  sinus,  the  tip  of  the  cannula  will  find  and  slip 
through  the  opening.  After  irrigation  of  the  sinus  the  patient  should  be 
directed  to  lower  the  head  between  the  knees  to  avoid  retention  of  fluid. 
When  the  condition  in  the  sinus  \\  ill  not  _\-ield  to  conservative  treatment  the 


ANAT()M^■  AXl)  SrKCI'.m-  OK  NOSE  AND  EAR  93 

entire  anterior  wall  can  he  readily  reniuved  from  the  ostium  downward  intra- 
nasally  or  by  the  more  radical  exposure:  hut  hefore  this  is  resorted  to,  the 
simple  irrigation  with  the  prohe-cannula  through  the  natural  opemng  should 
be  employed. 

In  case  of  chronic  inflammatory  conditions  and  in  new  growths  the  an- 
terior and  posterior  ethmoidal  cells  can  he  readil\  removed  with  a  bone  curette 
by  the  radical  exposure  after  removal  of  the  middle  turbinal  of  the  affected 
side.  The  parchmentlike  jiartiliou  walls  with  their  delicate  membrane  break 
itp  readily  with  such  an  instrument  and  the  greater  firmness  and  resilience  of 
the  orbital  wall  and  cribriform  plate  ofifer  a  safeguard  again.st  passing  be- 
yond these  important  barriers.  Thus,  after  removal  of  the  anterior  wall  of 
the  sphenoidal  sinus  with  the  bone  curette,  it  will  be  found  that  if  a  portion 
of  the  posterior  or  upper  wall  is  to  be  removed,  this  can  be  accomplished  only 
with  a  burr  or  chisel,  and  that  the  bone  curette  cannot  effect  the  same. 

The  inferior  turbinal  can  be  cut  away  with  curved  scis.sors;  the  lateral 
wall  of  the  nose,  which  corresponds  to  the  inner  wall  of  the  antrum,  can  be 
crushed  or  removed  with  bone  curette  or  bone-biting  forceps  in  in\dl\e- 
ment  of  this  part  of  the  nose. 

On  inspecting  the  posterior  and  upper  wall  of  the  sphenoidal  sinus,  a 
prominence  is  seen  which  corresponds  to  the  depression  of  the  sella  turcica 
and  contains  the  pituitary  body  (Plate  VIII).  For  the  removal  of  the  pitui- 
tary body  the  septum  and  middle  and  superior  turbinals  of  both  sides,  the 
ethmoidal  labyrinth  and  the  anterior  wall  of  the  sphenoidal  sinus  must  be  re- 
moved, because  as  before  mentioned,  the  pituitary  body  corresponds  to  the 
middle  of  the  prominence  in  the  sphenoidal  sinus.  Laterallv  to  this  midpoint, 
important  structures  will  be  encountered,  i.e.,  the  cavernous  sinus,  carotid 
artery  and  chiasm.  For  removal  of  the  entire  septum  curved  scissors  are 
used,  the  septum  being  severed  at  its  upper  and  lower  attachments. 

Thus  the  method  of  exposure  for  the  ethmoidal  cells  and  sphenoidal  sinus 
is  preferable  to  the  method  from  above  through  the  frontal  sinus  or  from 
below  through  the  maxillary  antrum,  Ijccause  all  the  parts  are  left  in  situ  and 
no  external  deformity  results,  since  the  nose  is  replaced  without  loss  of  bone 
other  than  that  caused  ])y  the  width  of  the  Gigli  saw,  the  external  scar  being 
practically  hidden  in  the  natural  depressions  on  either  side  of  the  nose  or  by 
artificial  means,  i.  e.,  the  use  of  large  rimmed  spectacles. 


IV 

ANATOMICAL  AND    SURGICAL  DESIDERATA   IN   THE  EX- 
POSURE AND   REMOVAL   OF  THE   PITUITARY   GLAND 


IV 

ANATOMICAL   AND    SURGICAL   DESIDERATA   IN    THE   EX- 
POSURE AND   REMOV.AL   OF  THE   PITUITARY   GLAND 

An  anteroposterior  section  of  the  head  shows  that  the  roof  of  the  nose, 
when  compared  to  the  parts  situated  anteriorly  and  posteriorly  to  it,  cor- 
responds, on  the  one  hand,  to  the  depression  at  the  root  of  the  nose,  and,  on 
the  other,  to  the  uppermost  part  of  the  sphenoidal  sinus,  the  anterior  wall  of 
which  slopes  down  posteriorly  and  forms  the  upper  half  of  the  posterior  wall 
of  the  nasal  cavity  (Plate  XXX).  Hence,  to  expose  the  sphenoidal  sinus,  an 
incision  at  the  root  of  the  nose  and  from  there  downward  is  sut^cient  and 
renders  opening  of  the  frontal  sinus  unnecessary.  The  entire  height  and 
width  of  the  interior  of  the  nasal  foss;e  can  be  exposed  by  turning  the  nose 
downward.  An  incision  is  made  on  either  side,  starting  below  at  the  widest 
part  of  the  bony  nasal  aperture  (pyriform  fossa)  and  passing  upward  to  the 
depression  at  the  root  of  the  nose.  These  two  incisions  are  united  by  a  cross 
incision,  the  scalpel  passing  through  all  the  tissues  down  to  the  bone  (  Plate 
XXXI).  The  periosteum  of  the  osteoplastic  flap  is  not  interfered  with,  but 
that  lying  opposite  is  pushed  backward  toward  the  face  only  enough  to  ac- 
commodate the  width  of  a  Gigli  saw,  which  is  now  used,  beginning  with  a 
cut  at  the  root  of  the  nose  to  form  a  groove  (which  will  fi.x  the  saw  for  its 
downward  course)  and  then  continuing  through  the  bone  freed  of  its  perios- 
teum until  the  lower  end  of  the  incision  has  been  reached.  A  retractor,  grasp- 
ing the  flap  above  and  drawing  it  forward,  will  open  a  cleft  into  which  a 
scalpel  can  lie  introduced  to  complete  the  separation  of  the  cartilage  of  the 
septum  sufficiently  to  permit  complete  depression  of  the  nose,  thus  exposing 
the  full  height  and  width  of  the  nasal  fossae.  The  hinge  of  the  soft  part, 
which  remains  below,  contains  the  terminal  branches  of  the  facial  arteries, 
which  will  nourish  the  osteoplastic  flap  thus  formed.  With  curved  scissors 
directed  along  the  roof  of  the  nose,  the  septum  can  be  severed  superiorlv  and 
posteriorly  along  the  sloping  anterior  wall  of  the  sphenoidal  sinus.  In  order 
to  facilitate  the  grasping  of  the  bleeding  vessels,  I/2  centimeter  of  the  septum 
should  be  left  standing  above  while  posteriorly  it  is  cut  close  to  the  sinus 
wall.  To  expose  this  anterior  wall  of  the  sinus,  straight  scissors  should 
now  be  used  to  cut  the  septum,  from  below  and  in  front,  upward  and  back- 
ward to  the  middle  of  the  posterinr  wall  nf  the  nasal  cavity.    A  wedge-shaped 

97 


PLATE    XXX 


Anteroposterior  section  of  head,  showing  incision  line  of  nose  and  septum  for 
exposing  interior  of  nose.  Also  part  of  septum  (wedge)  to  be  removed  for 
exposing  sphenoidal  sinus  and  pituitary  gland. 


98 


PLATE    XXXI 


External  line  of  incision,  showing  extent  to  which  bones  are  divided  hv  tiie  GigH  saw. 


99 


loo    ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

section  of  septum  is  tluis  removcil,  prijclucin,:,^  a  funiiel-sliaped  cavity,  the 
opening  of  which  corresponds  to  the  outer  border  of  the  nasal  cavity  and 
the  smaller  end  to  the  anterior  wall  of  the  sphenoidal  sinus,  which  must  be 
removed.  Only  in  the  event  of  prcjtruding  middle  turbinals  and  prominent 
lateral  masses  of  ethnniid  cells  should  these  lie  interfered  with.  This  is  best 
done  by  cutting  away  the  turbinals  with  straight  scissors  and  remo\-ing  the 
cell  masses  by  means  of  a  bone  curette  or  forceps.  A  greater  resistance 
present  after  ethmoid  cells  have  been  removed  indicates  the  orbital  plate. 
The  same  resistance  is  met  at  the  roof  of  the  nose  and  acts  as  a  barrier,  pre- 
venting exposure  of  the  dura. 

After  the  anterior  wall  of  the  sphenoidal  sinus  is  removed  by  means  of 
chisel  and  bone-cutting  forceps,  the  prominence  on  the  posterior  wall  becomes 
apparent.  This  prominence  is  the  depression  caused  by  the  floor  of  the  sella 
turcica,  and  that  part  of  it  corresponding  to  the  median  line  of  the  skull 
must  be  removed  to  reach  the  pituitary  gland.  Oftentimes  the  septum  be- 
tween the  sphenoidal  sinuses  is  irregularl}-  placed  to  one  or  other  side  of 
the  median  line  of  the  skull,  or  starts  on  one  side  or  other  above  and  runs  to 
the  opposite  side  below:  frecjuently  it  is  entirely  absent.  Therefore,  to  ex- 
pose the  pituitary  body,  it  is  essential  to  choose  the  median  line  of  the 
skull,  not  permitting  the  irregularly  attached  sphenoidal  septum  to  detract 
from  removal  of  the  midportion  of  the  prominence  on  the  posterior  wall 
of  the  sinus.  This  should  l)e  confined  to  the  central  portion  to  avoid  injuring 
the  cavernous  sinuses  and  carotid  arteries  on  either  side,  and  a  button  about 
half  a  centimeter  in  diameter  should  be  removed  with  a  trephine  or  a  long- 
handled  gouge,  its  concave  surface  directed  toward  a  central  point.  For  a 
decompression  operation  to  relieve  the  tension  of  a  tumor,  more  of  this 
posterior  wall  must  be  removed.  After  the  bone  corresponding  to  the  floor 
of  the  sella  turcica  has  l:)een  removed,  the  cavity  is  recognized  by  probing,  the 
resistance  of  the  posterior  wall  of  the  sella  turcica  (dorsum  sellre)  indicating 
the  exact  location  of  the  cavity  sought  for.  Removal  of  the  gland  can  be 
accomplished  by  means  of  a  long-handled  scoop  or  curette. 

The  purpose  of  the  procedure  having  been  accomplished,  the  nose  is 
brought  back  into  place  and  secured  by  several  sutures  for  the  deeper  tissues 
and  periosteum  and  finally  some  for  the  skin.  In  this  way  the  greater  part 
of  the  interior  of  the  nasal  cavitv  remains  intact  and  the  part  sought  for  is 
completely  exposed,  illumination  of  the  depth  of  the  cavity  being  accom- 
plished by  means  of  a  head  light  or  an  electric  pencil  directed  to  the  field  of 
operation. 


V 
POSTURAL  TREATMENT  OF  OTITIS  MEDIA  AND  MASTOIDITIS 


V 

POSTURAL  TREATMENT  OF  OTITIS  MEDIA  AND  MASTOIDITIS 

During  the  past  few  years  operative  procedure  has  become  so  common 
in  otology  that  with  many  surgeons  the  sHghtest  sign  of  involvement  of 
the  mastoid  antrum  complicating  an  otitis  media  is  considered  an  indication 
for  operative  interference.  A  better  understanding  of  the  anatomical  rela- 
tions of  the  parts,  together  with  the  application  of  one  of  the  fundamental 
principles  of  successful  surgery,  that  is,  drainage,  would  lead  to  a  more  con- 
servative line  of  treatment  in  a  direction  that  seems  to  have  been  entirely  over- 
looked, namely,  the  posture  of  a  patient  with  otitis  media  or  mastoiditis. 
The  relationship  of  the  middle  ear  and  antrum  is  such  that,  if  an  inflammatory 
exudate  is  present  in  the  middle  ear  and  the  patient  is  lying  on  his  back,  the 
secretions  will  flow  by  gravity  from  the  middle  ear  through  the  aditus  ad 
antrum  to  the  mastoid  antrum  itself.  The  presence  of  a  secretion  will,  of 
course,  irritate  the  membrane  lining  the  antrum  and  produce  mastoiditis, 
even  though  the  inflammation  has  not  extended  from  the  middle  ear.  Let 
us  recall  for  a  moment  the  exact  relations  of  the  parts  in  the  tympanic  cavity. 
(See  Plate  XXXIL) 

Anteriorly  is  the  opening  of  the  Iiustachian  tube.  It  is  tlirough  this  tube 
that  an  inflammation  originating  in  the  nose  or  pharynx  extends  and  causes 
an  in\olvement  of  the  middle  ear.  The  mucous  membrane  lining  the  tube 
swells  and  clogs  this  channel  temporarily.  The  natural  passage  through 
which  the  middle  ear  is  aerated  and  drained  is  closed,  and  the  result  is  a  re- 
tention of  the  inflammatory'  secretions  within  the  middle  ear,  which  aggra- 
vates the  already  inflamed  membrane.  If  not  relieved  there  is  in  time  a 
bulging  of  the  tympanic  membrane  accompanied  by  great  pain,  and  if  a 
paracentesis  is  not  performed  an  extension  to  attic,  aditus,  and  antrum  oc- 
curs. If  the  drainage  through  the  perforation  is  sufficient,  the  process  of 
repair  sets  in  and  frecjuently  the  inflammation  of  the  entire  tract  subsides, 
even  though  it  has  extended  tn  the  attic,  aditus,  and  antrum.  If  pus  is 
present,  there  is  an  erosion  of  the  membrane  which,  owing  to  interference 
of  the  circulation  from  pressure,  has  become  less  resistant,  and  a  perfora- 
tion results — which  gives  relief  from  the  symptoms  of  pressure.  As  far  as  the 
middle  ear  is  concerned,  the  tendency  now  is  to  repair.  But  what  happens 
to  the  antrum  if  it  has  become  filled  w'nh  the  exudate?     As  these  cases  are 

103 


I04    ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

now  ordinarily  treated,  the  patient  is  permitted  either  to  sit  erect  or  lie  on 
the  back,  or  occasionally  on  his  side.  In  the  recumbent  position  the  irritating 
discharge  remains  in  the  antrum  and  causes  an  inflammation  which,  in  turn, 
adds  to  the  exudate,  of  which  only  the  overflow  leaves  the  antrum  through 
the  aditus. 

The  inflamed  membrane  goes  on  to  ulceration  and  eventually  to  necrosis 
of  the  bony  lining,  with  further  involvement  of  efferent  veins  and  lymph 
chamiels,  infecting  all  the  important  surrounding  structures  and  thus  estab- 
lishing the  various  complications  of  middle  ear  disease.  If  the  mastoid 
process  is  cancellous,  the  extension  of  the  inflammation  to  other  pneumatic 
cells  thrdughout  the  process  may  be  very  rapid.  Necrosis  extending  back- 
ward from  the  antrum  soon  reaches  the  bony  lining  of  the  lateral  sinus,  or 
the  inflammation  may  extend  through  the  connecting  veins  of  the  sinus, 
producing  a  thrombosis  of  the  lateral  sinus,  without  antecedent  necrosis. 

Referring  again  to  die  anatomical  relations,  we  have  externally  the  drum 
membrane:  internally,  the  bony  inner  wall,  with  exception  of  the  membrane 
of  the  round  window;  above,  the  ossicles  and  the  bony  roof;  posteriorly,  a 
bony  wall  below  and  an  opening  above,  that  is,  the  aditus  or  passage  which 
leads  to  the  antrum.  The  position  of  this  passage  high  up  on  the  posterior 
wall  und(jni)tedly  in  many  cases  prevents  the  inflammatory  process  from 
reaching-  the  antrum.  On  the  other  hand,  when  the  antrum  is  once  involved 
and  the  patient  is  allowed  to  rest  on  his  back,  the  position  of  the  aditus  in 
its  relation  to  the  antrum  is  such  that  the  acrid  secretions  are  prevented  from 
leaving  the  latter,  and  thus  is  produced  all  the  trouble  we  are  familiar  with. 
What  then  can  be  done  to  relieve  this  apparent  faulty  provision  of  nature 
when  inflammation  ensues?  This  apparently  faulty  provision  of  nature 
is  really  an  excellent  one  and  finds  its  parallel  in  the  accessory  sinuses  of 
the  nose. 

The  ostia  of  the  maxillary,  frontal,  and  sphenoidal  sinuses  also  are  at 
the  highest  point  possible  and  well  protected,  so  that  no  extraneous  matter 
from  the  inhaled  air  can  enter  and  infect  them.  When,  however,  inflamma- 
tion occurs,  the  ostia  are  most  unfavorably  situated  for  draining  the  cavities, 
and  if  relief  is  not  given  by  posture  they  must  be  opened  at  the  most  de- 
pendent point.  This  c|uestion  of  drainage  is  the  all-important  factor  in  the 
successful  management  of  these  cases,  and  the  anatomical  relations  point  out 
the  proper  course  to  pursue.  If  the  middle  ear  or  antrum  is  to  be  drained, 
the  patient  should  be  placed  in  such  a  position  that  it  will  drain.  And  what 
is  this  position?    It  is  one  In  u'liicli  the  antrum  is  placed  at  a  higher  clez'ation 


PLATE   XXXII 


M 


C  A 


M  A 


r  M 


ET 


Base  of  the  skull  seen  from  aljove  with  the  dura  mater  intact,  except  over  a  portion 
of  the  temporal  l.ione  where  it  and  the  bone  have  been  cut  away  to  expose  the 
Eustachian  tube,  the  tympanic  cavity,  the  attic,  aditus  ad  antrum,  and  the  mas- 
toid antrum. 

M,  Long  process  of  malleus. 

C  A,  Carotid  artery. 

M  A,  Mastoid  antrum. 

I.  Short  process  of  the  incus. 

T  M,  Tympanic  membrane,  with  perforation. 

E  T,  Eustachian  tube. 

105 


io6  ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

than  tlic  middle  car,  and  the  middle  car  higher  than  the  Eustachian  tube,  its 
natural  outlet  or  drain.  With  a  patient  lying  face  downward — the  forehead 
and  one  cheek  supported  by  pillows,  the  nose  and  mouth  and  one  eye  free — 
perfect  drainage  can  be  procured.  When  the  patient  is  made  to  realize  the 
importance  and  advantages  of  this  posititjn,  he  will  not  only  assume  it  from 
necessity,  but  even  adopt  it  by  preference  as  a  comfortable  posture  during 
sleep.     Now,  what  happens  in  this  posture? 

If  an  otitis  media  alone  exists,  the  secretion  will  drain  through  the 
Eustachian  tube,  provided  it  is  not  clogged,  or  through  a  perforation  of  the 
drum  membrane,  if  such  exists.  This  would  prevent  antrum  involvement, 
which  might  have  occurred  if  the  secretion  had  been  allowed  to  tlow  into 
it  and  Ije  retained  there.  If  the  antrum  is  already  inflamed,  the  secretion, 
flowing  off  through  the  aditus  into  the  middle  ear  and  out  as  before,  will 
enable  the  mucous  membrane  lining  it  to  proceed  to  repair,  and  erosion  of  it 
and  necrosis  of  the  underlying  bone  will  not  occur.  Even  though  the  external 
svmptoms  of  pain  nn  pressure  and  edema  over  the  mastoid  process  have 
occurred,  generally  these  will  gradually  subside  and  disappear,  and  an  opera- 
tion with  a  tedious  and  painful  after-treatment  will  become  unnecessary. 
The  management  of  otitis  media  or  mastoiditis  is,  therefore,  as  follows : 
A  purgative  is  given  to  aid  in  relieving  the  local  congestion  in  the  af- 
fected area.  The  rhinitis  or  pharyngitis,  whichever  ma_\-  have  been  the 
causative  factor  in  the  involvement  of  the  Eustachian  tube,  receives  the 
utmost  attention,  the  greatest  efforts  being  directed  to  the  Eustachian  open- 
ing and  nasopharynx.  Following  this,  the  tube  itself  is  treated  in  order  to  re- 
duce the  swelling  of  its  lining  membrane,  to  render  it  patent,  and  thus  ef- 
fectually to  drain  the  middle  ear.  The  patient  is  directed  to  produce  suction 
in  the  Eustachian  tulie  by  swallowing  water,  with  the  nose  and  mouth  closed, 
several  times  daily.  If  these  measures  do  not  suffice  to  relieve  the  condi- 
tion in  the  middle  ear  without  operative  procedure,  paracentesis  of  the  drum 
membrane  should  be  performed.  Instead  of  the  ordinary  puncture  of  the 
membrane,  I  incise  it  from  its  midpoint  (tip  of  long  process  of  malleus) 
downward,  and  make  a  second  incision  posteriorly,  beginning  half-way  up  and 
curving-  downward  and   forward  until  the  second  and  first  incisions  meet, 

o 

thus  forming  a  flap.  This  gives  a  larger  opening  than  a  single  incision,  and, 
besides  permitting  free  draining,  is  large  enough  for  introducing  a  small 
cannula  for  irrigating  the  middle  ear.  In  douching  the  tympanic  cavity  in 
mastoiditis  the  stream  should  be  directed  upward  and  backward  toward  the 
aditus.     The  patient  is  advised  to  lie  face  downward  most  of  the  time,  and 


ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR  107 

occasionally  upon  the  affected  side.  The  Eustachian  lube  should  be  treated 
through  the  nose  by  means  of  a  catheter,  through  which  a  mild  antiseptic  and 
detergent  solution  may  lie  introduced;  this  Hows  out  through  the  perforation 
in  the  drum.  ( )n  the  other  hand,  if  in  irrigating  the  t\ni]ianic  cavity  the 
Eustachian  tube  is  patent,  the  solutinn  will  llnw  out  of  the  nose  or  into  the 
throat.  For  irrigating  through  a  perforation,  a  thin  cannula,  bent  at  the 
end  and  attached  to  a  ruljber  l)ulli  placed  at  an  angle  permitting  exact  intro- 
ducti<jn  by  sight,  should  be  used.  The  irrigations  are  performed  by  the  at- 
tending physician  twice  daily  or  at  longer  intervals  according  to  the  stage 
of  the  process.  This  frees  the  middle  ear,  the  aditus,  and  the  Eustachian 
tube,  and  as  soon  as  the  secretions  have  diminished  and  drainage  is  sufficient 
through  the  Eustachian  tube,  the  flap  made  in  the  drum  mav  be  allowed  to 
fall  back  into  place  and  to  close  the  perforation,  forming  a  perfect  mem- 
brane instead  of  the  large  perforations  that  are  liable  to  result  from  other 
incisions.  The  patient  himself  douches  the  outer  ear  at  more  frequent 
intervals,  and  retains  the  prone  posture  for  the  greater  part  of  the  time 
between  treatment.  Before  douching,  the  patient  is  instructed  to  introduce 
a  detergent  and  cleansing  solution  full  strength  into  the  outer  ear  to  be 
retained  for  from  fi\e  to  ten  minutes  while  lying  on  the  other  side. 

Adrenalin,  alcohol,  powders,  or  other  medicaments  may  be  used  as  indi- 
cated, to  hasten  the  process  of  repair.  I  am  also  in  the  habit  of  having 
patients  take  one-half  gallon  of  some  alkaline  water  during  the  twenty- four 
hours,  as  I  believe  it  thins  the  discharge,  causes  it  to  flow  off  more  rapidl\-,  and 
prevents  accumulation  and  formation  of  crusts. 

In  several  instances  of  severe  otitis  media  and  mastoiditis,  in  which,  in 
the  opinion  of  eminent  otologists,  it  was  deemed  necessary  to  operate  imme- 
diateh',  I  have  been  aljle  by  this  more  conservative  treatment  to  cure  the  condi- 
tion present ;  and  I  feel  that  by  this  simple  method,  I  have  prevented  many 
cases  of  otitis  media  from  developing  into  operable  mastoiditis.  Of  the 
measures  used  the  postural  treatment  was  probably  the  most  essential. 


VI 

A  CONTRIBUTION  TO  THE  ANATOMY  AND  SURGERY  OF 

THE  TEMPORAL  BONE 


VI 

A  CONTRIBUTION  TO  THE  ANATOMY  AND  SURGERY  OF  THE 

TEMPORAL  BONE 

Tlie  recent  additions  to  the  symptomatology  and  diagnosis  of  complica- 
tions and  sequelce  of  middle-ear  disease,  with  the  resulting  surgical  inter- 
ference in  deep-seated  affections,  have  made  it  necessary  to  acquire  a  more 
intimate  knowledge  of  the  landmarks  of  the  ear  and  its  surrounding  struc- 
tures. The  present  article,  with  the  accompanying  charts  drawn  from  dis- 
sections on  the  cadaver,  is  intended  to  fill  a  requirement  still  existing  in  our 
medical  literature  and  to  serve  as  a  guide  for  improved  technifjue  in  the 
future  for  attacking  the  temporal  lione  and  vital  parts  in  its  immediate 
neighborhood. 

In  the  comparatively  simple  procedure  of  entering-  the  mastoid  antrum  an 
incision  through  the  skin,  fascia,  and  periosteum,  beginning  behind  the  at- 
tachment of  the  auricle,  at  a  point  corresponding  to  the  upper  wall  of  the 
external  auditory  meatus  and  passing  over  the  middle  of  the  mastoid  process 
to  its  tip,  will  suffice,  if  the  tissues  are  drawn  forward,  to  expose  sufficient 
bone  to  appreciate  the  landmarks  necessary  for  this  operation.  In  the  more 
extensive  procedure  of  attacking  the  middle  ear  and  its  adjacent  parts,  a 
longer  incision  is  necessary.  The  incision  begins  at  a  point  above  the  ear 
sufficiently  far  back  to  avoid  the  temporal  artery,  then  courses  downward 
^  to  I  cm.  behind  the  attachment  of  the  auricle,  in  order  to  avoid  severing 
the  posterior  auricular  artery,  and  ends  at  the  tip  of  the  mastoid  process 
(Plate  XXXIII). 

When  the  tissues  are  dissected  and  retracted  a  field  will  be  exposed  in 
which  the  entire  outer  and  middle  ear,  as  well  as  the  mastoid  antrum  and 
the  sigmoid  flexure  of  the  lateral  sinus,  can  be  reached  (Plate  XXXIV). 
Above  the  temporal  ridge  this  incision  should  pass  through  skin  alone,  ex- 
posing the  temporal  fascia  covering  the  temporal  muscle ;  this  should  not 
be  severed.  Below  the  ridge  it  should  pass  directly  to  the  bone  of  the  mas- 
toid process.  The  anterior  flap  should  contain  the  auricle  with  the  perios- 
teum from  the  mastoid  process  and  the  entire  soft  parts  of  the  external 
auditory  meatus,  the  periosteum  of  the  meatus  remaining  continuous  with 
that  covering  the  mastoid  process.  On  elevating  the  periosteum  and  retract- 
ing the  tissues  still  covering  the  process  behind,  an  area  will  be  exposed  suf- 

III 


X 
X 

w 

< 

Pi 


Rl 


c 
o 


'o 


o 
X 


ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR  113 


Line  of  incision 

for 
mastoid  operation 


ficient  for  the  most  radical  operation  on  the  temporal  hone,  even  to  the  extent 
of  its  entire  removal. 

The  following  are  the  landmarks  visible  from  above  downward  (Plate 
XXXIV).  Above  the  temporal  ridge  or  crest  is  the  fascia  covering  the 
temporal  muscle.  The  crest  is  the  continuation  l:>ackward  of  the  zygomatic 
arch  and  affords  attachment  to  the  fascia  as  well  as  the  tenip(jral  muscle,  and 
corresponds  in  height  to  the  upper  wall  of  the  bony  auditory  canal ;  it  forms 
the  division  line  between  the  squamous  and  mastoid  portions  of  the  temporal 
bone,  and  serves  as  a  landmark  for  opening  the  mastoid  antrum  and  lateral 
sinus. 

In  a  simple  mastoid  operation  the  external  opening  should  remain  below 
this  crest  in  order  to  avoid  entering  the  cereliral  cavity. 

Below  the  crest  and  in  front  of  the  mastoid  process  is  seen  the  external 
auditory  meatus,  a  long,  funnel-shaped  canal,  the  walls  of  which  are  formed 


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I20    ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

by  tlic  tympanic  plate.     The  free  margin  uf  this  plate  (the  auditory  process) 
affords  attachment  to  the  cartilage  of  the  ear. 

In  the  depth  oi  the  meatus  is  seen  the  txmjjanic  membrane  or  ear  drum, 
lodged  in  a  ring  of  bone  with  the  manubrium  or  handle  of  the  malleus,  at- 
tached to  and  shining  through  its  upper  half,  slanting  from  above  and  in 
front  downward  and  backward.  The  upper  portion  of  the  membrane  is 
thrown  into  folds  by  the  outward  projection  of  the  processus  brevis  of  the 
malleus,  which  springs  from  the  upper  part  of  the  manubrium  close  to  the 
tympanic  ring.  The  portion  of  the  membrane  thus  affected  is  called  Shrap- 
nell's  membrane. 

On  removing  the  t}nipanic  membrane  from  its  ring  of  bone  and  from 
its  attachment  to  the  malleus,  the  tympanic  cavity  or  middle  ear  is  exposed 
and  the  following  points  of  interest  noted  (Plate  XXXV)  :  In  the  upper 
half  of  the  cavity  are  seen  anteriorly  the  manubrium,  projecting  downward 
and  slightly  backward,  with  the  processus  brevis  at  its  upper  end  close  to 
the  rim  of  the  bony  canal.  The  processus  longus  of  the  incus  is  situated 
half  a  millimeter  behind  and  parallel  to  the  manubrium,  and  has  its  lower 
end  attached  to  the  stapes.  The  lower  half  of  the  cavity  presents  a  rounded, 
glistening  eminence,  called  the  promontorium,  and  an  opening  directly  be- 
hind it  called  the  fenestrum  rotundum.  The  latter  opens  into  the  cochlea,  of 
which  the  promontorium  represents  the  first  turn. 

In  order  to  expose  the  tympanic  cavity  or  middle  ear  more  thoroughly,  a 
part  of  the  superior  and  posterior  walls  of  the  external  meatus  can  be  re- 
moved (Plate  XXXAT).  The  tympanic  cavity  (as  seen  in  the  last  plate) 
has  its  upper  part,  the  attic,  hidden  behind  the  inner  portion  of  the  upper 
w^all  of  the  external  auditory  meatus.  Hence,  the  upper  wall  of  the  meatus 
corresponds  to  the  outer  wall  of  the  attic,  and  with  the  procedure  just  men- 
tioned the  attic  is  exposed. 

The  attic  contains  the  heads  and  bodies  of  the  malleus  and  incus,  and  the 
removal  of  its  outer  wall  shows  these  bones  in  fofo.  Besides  these  structures 
the  tensor  t\-mpani  muscle  can  be  seen  anteriorly  emerging  from  its  canal 
and  becoming  mserted  into  the  neck  of  the  malleus.  The  short  process  of 
the  incus  is  seen  projecting  back  into  the  aditus,  while  the  long  process 
descends  to  become  attached  to  the  stapes.  Beneath  the  short  process  of. 
the  incus  the  chorda  tympani  nerve  emerges  from  the  facial  canal  in  the 
posterior  wall.  It  crosses  the  long  process  of  the  incus  and  disappears  behind 
the  malleus.  ^Vhen  this  nerve  is  injured  accidentally  or  otherwise,  the  sense 
of  taste  for  the  corresponding  side  of  the  tongue  is  lost.     Directly  internal 


ANATOMY'    \XI)  SL-|>:(;ERY  of  nose  and  ear  121 

to  the  tip  of  the  long  pr(jcess  of  the  incus  lies  the  stapes  placed  at  right 
angles  to  it.  To  the  neck  of  the  latter  is  attached  the  stapedius  muscle,  which 
consists  of  minute  lihers  i  to  2  mm.  in  length  coming-  from  the  pyramidal- 
shaped  cavity  in  the  posterior  wall  of  the  tympanum.  In  the  background,  por- 
tions of  the  inner  wall  of  the  middle  ear  are  visible.  Directly  above  the  stapes 
and  behind  the  incus  is  the  projection  of  bone  co\-ering  the  facial  nerve. 
Below  the  stapes,  the  promontorinm  and  fenestmm  rotundum  are  again  seen 
as  before. 

At  the  upper  posterior  angle  oi  the  entrance  to  the  bony  meatus  is  a 
spicule  of  bone  known  as  the  suprameatic  spine  ( Plates  XXXIV  to 
XXXVII).  This  is  of  importance  in  the  simple  mastoid  operation,  as  it  is 
prominent  in  most  skulls,  and  when  felt,  serves  as  a  landmark,  being  the 
most  anterior  priint  to  which  the  tissues  should  be  dissected,  and  also  the 
point  I  cm.  behind  which  the  opening  for  entering  the  antrum  should  be 
liegun.  The  mastoid  process  (Plate  XXXIV),  of  which  the  temporal  ridge 
forms  the  base  line,  has  been  denuded  of  periosteum.  Near  its  posterior  bor- 
der is  situated  the  mastoid  foramen,  through  wdiich  one  of  the  emissary  veins 
of  the  lateral  sinus  passes.  Below,  the  process  has  the  sternocleidomastoid 
muscle  attached  to  it.  The  fibers  of  this  should  be  left  intact  when  these  parts 
are  exposed,  excepting  in  tliosc  instances  in  which  their  presence  interferes 
with  the  thorough  exploration  of  the  mastoid  cells. 

The  nature  of  the  bony  structure  of  the  process  varies  greatly  in  dif- 
ferent subjects,  being  \ery  compact  tissue  (small  celled  or  diploic)  in  some 
and  cellular  ( large  celled  or  pneumatic  )   in  others. 

To  reach  the  antrum,  the  chisel  or  burr  drill  must  be  placed  at  a  point 
I  cm.  behind  the  suprameatic  spine,  and  keeping  below  the  temporal  crest,  or 
the  upper  wall  of  the  meatus,  must  penetrate  a  mass  of  bony  tissue  to  a 
depth  varying  from  i  cm.  to  2  cm.  in  a  direction  inward,  forward,  and 
slightly  upward,  corresponding  to  the  direction  of  the  external  auditory 
canal.  The  position  of  the  antrum  varies  somewhat.  Although  it  is  generally 
situated  about  J^S  to  i  cm.  behind  the  outer  opening  of  the  auditory  canal, 
it  is  sometimes  found  almost  directly  internal  to  its  upper  wall.  The  depth 
at  which  the  antrum  is  met  also  varies,  but  it  is  safe  to  say  that  if  the 
instrument  penetrates  deeper  than  1J2  cm.,  and  be  directed  too  far  forward 
or  downward,  the  horizontal  simecircular  canal  or  the  aqu.'eductus  Fallopii 
will  be  encountered  (Fig.  XXXIX).  If  the  former  were  opened  in  a 
purulent  otitis  media  the  pus  would  travel  along  it  to  the  vestibule  and  from 
there  into  the  internal  auditory  meatus,  producing  a  pachymeningitis  or  ex- 


122  ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

tratlural  (epidural)  abscess  of  the  posterior  fossa  of  the  skull;  or  from  the 
vestiljule  through  the  perpendicular  semicircular  canal,  which  if  accompanied 
by  erosion  of  its  bony  covering-  would  lead  to  inxolvement  of  the  meninges 
of  the  middle  fossa.  The  same  would  hold  good  for  the  posterior  semi- 
circular canal  affecting  the  posterior  fossa. 

If  the  latter  (the  aqu?eductus  Fallopii)  were  opened  an  inflammation  of 
the  facial  ner\ e  which  is  contained  therein  would  result,  producing  paralysis 
of  that  side  nf  the  face.  The  inflammatory  pr(_)cess  might  also  find  its  way 
through  the  entire  canal  to  the  internal  auditory  meatus,  causing  a  pachy- 
meningitis or  extradural  abscess  as  mentioned  above;  or,  traveling  along  the 
nerve  to  its  cerebral  attachment,  would  produce  a  meningitis  or  subdural 
(intradural)  abscess.  The  direction  of  the  penetrating  instrument  must  also 
be  forward,  in  order  to  avoid  injuring  the  lateral  sinus. 

For  extensive  dissections  on  the  mastoid  process,  where  involvement  of  the 
antrum  as  well  as  the  lateral  sinus  and  the  mastoid  cells  is  suspected,  a  divi- 
sion of  the  process  into  four  diual  parts  suggested  itself  to  Dr.  Hartley,  and 
the  following  procedure  has  been  evolved*  (Plates  XXXV,  XXXVI,  and 
XXX\TI~)  ;  The  temporal  ridge,  or  a  line  continuous  with  the  zygomatic 
arch,  is  taken  as  the  upper  boundary ;  the  anterior  border  of  the  mastoid 
process,  as  the  anterior  boundary;  a  line  drawn  vertically  from  the  junction 
of  the  posterior  border  of  the  mastoid  process  where  it  meets  the  occiput,  as 
the  posterior  boundary;  and  an  imaginary  line  drawn  backward  from  the 
tip  of  the  mastoid  process,  as  the  lower  boundary  of  a  cjuadrangle.  On 
dividing-  this  into  four  equal  parts  it  was  found  that  in  almost  every  instance 
the  upper  anterior  quadrant  opened  into  the  mastoid  antrum,  the  upper 
posterior  quadrant  opened  into  the  lateral  sinus,  and  the  two  lower  quadrants 
into  mastoid  cells.  The  lower  posterior  quadrant  also  opens  into  the  de- 
scending limb  of  the  lateral  sinus  if  gone  into  sufficiently  deep. 

In  permitting  a  wall  of  bone  to  remain  separating  the  anterior  and 
posterior  (|uadrants,  a  safeguard  is  established  which  prevents  the  infec- 
tious flischarge  which  might  be  found  in  the  anterior  quadrant  ('antrum), 
entering  and  setting  up  a  similar  process  in  the  posterior  quadrant  with  its 
lateral  sinus,  providing  this  has  been  exposed  and  found  to  be  healthy  and 
patent. 

In  this  wa\-,  if  anv  doubt  exists  as  to  the  extent  of  infection,  the  entire 
surface  of  the  mastoid  can  be  immediately  mapped  out,  and  the  upper  an- 

*  In  Chipault's  Siii'gi-''>'\'  reference  is  made  to  the  division  of  the  mastoid  process  for 
the  purpose  of  locating  the  lateral   sinus. 


ANATOMY  AND  SURCRRY  OF  NOSR  AND  EAR  123 

tericir  (|ua(lraiU  opened  llrst  l^  delermiiie  if  the  antrum  is  involved  (i'late 
XXXVl).  If  this  he  su  and  the  mastoid  eells  tliemselves  contain  pus,  one 
or  l)oth  lower  quadrants  ean  be  opened  rmd  evacuated.  If  the  i)r(jcess  is  very 
extensive,  and  there  is  reason  to  suspect  an  infected  thrombus  in  the  descend- 
ing limb  of  the  sigmoid  flexure  of  the  lateral  sinus,  which  is  the  most  fre- 
quent site  for  a  beginning  thrombus,  the  upper  posterior  quadrant  can  be 
gone  into,  the  siiuis  punctured  with  a  hypodermic  needle  or  incised,  if  suf- 
ficiently exposed,  and  the  nature  of  its  contents  determined.  The  bridges 
of  bone  between  the  quadrants  have  the  advantage  over  a  continuous  bony 
wound,  made  by  chiseling  off  the  entire  outer  surface  of  the  mastoid,  as 
performed  by  many  surgeons,  on  account  of  the  support  given  the  tissues 
which  preser\-e  the  original  contour  of  the  parts,  and  the  liarriers  which  they 
form  between  infected  and  non-infected  areas. 

The  descending  limb  of  the  lateral  sinus  is  met  at  a  depth  ranging  from 
^  to  I  cm.,  and  is  usually  seen  taking  a  somewhat  slanting  course  from 
above  and  Ijehind,  dtiwn  and  forward :  it  then  dips  in  forming  the  sigmoid 
flexure.  The  sinus  generally  fills  the  upper  posterior  quadrant,  but  at  times 
it  will  be  seen  only  in  the  posterior  half  or  two-thirds  of  the  quadrant,  and 
in  these  cases  the  quadrant  can  be  enlarged  posteriorly.  Frequently  the 
mastoid  vein  can  be  seen  entering  the  sinus  at  this  point  (Plate  XXXA^I). 
This  vein  is  of  importance  in  case  of  periostitis  of  the  mastoid  process,  as  the 
inflammation  of  its  walls  and  its  extension  inward  may  be  the  origin  of 
a  thrombus  of  the  lateral  sinus ;  and  in  cases  where  the  thrombus  of  the 
sinus  already  exists,  the  blood  which  is  dammed  up  in  the  mastoid  vein 
produces  edema  of  the  tissues  which  it  drains,  and  becomes  of  diagnostic 
importance  in  determining  the  former  conditio:!. 

On  returning  to  the  description  of  the  middle  ear  we  find  that  by  severing 
the  tensor  tvmpani  muscle  in  front,  and  the  articular  attachment  of  the 
incus  below,  both  the  malleus  and  incus  can  ])e  removed,  lea^'ing  the  stapes 
in  situ  (Plate  XXXVII).  On  removal  of  these  two  ossicles,  the  entire  inner 
wall  of  the  tympanum  can  be  seen.  The  upper  part,  which  also  forms  the 
inner  wall  of  the  attic,  consists  of  a  rounded  projection,  formed  by  the 
horizontal  semicircular  canal  above  and  a  lighter  strip  below,  made  up  of 
a  thinner  plate  of  bone  covering  the  facial  ner\e  .and  forming  the  aqua^ductus 
Fallopii.  The  aqusductus  Fallopii  extends  farther  forward  than  the  semi- 
circular canal  t"  the  anterinr  and  uppermost  angle  of  the  tympanic  cavity. 
Below  this  projection  the  stapes  is  seen  lodged  in  the  fenestrum  ovale,  with 
the   stapedius   muscle,    coming    from   behind,    inserted    into    its    neck.      The 


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I30  ANATOMY  .\ND  SURGERY  OF  NOSE  AND  EAR 

promt iiilc.ry  and  tenestrum  rutuuclum  forming  llie  lower  half  of  the  inner 
wall  are  seen  to  better  ailvanlage.  The  chorda  tympani  nerve  has  been  re- 
moved. 

To  effect  a  more  thorough  and  immediate  exposure  of  the  entire  middle 
ear,  when  radical  measures  are  intended,  the  removal  with  a  chisel  of  the 
tympanic  plate  as  far  as  the  styloid  process,  in  combination  with  the  re- 
moval of  part  of  the  upper  and  posterior  walls  of  the  external  auditory  canal, 
will  be  found  of  the  greatest  advantage  as  a  preliminary  step  (Plate 
XXXVIII).  By  removal  of  this  plate  of  bone  and  the  superficial  lamina  of 
the  anterior  surface  of  the  mastoid  process  the  entire  facial  nerve  can  be 
exposed  and  located  and  followed  to  the  bend  in  the  nerve  at  the  upper 
anterior  angle  of  the  tympanic  cavity.  The  nerve  is  lodged  at  a  depth  of 
2  cm.  from  the  external  surface  of  the  mastoid  process.  Hence,  no  fear 
need  be  entertained  of  its  injury  in  this  part,  as  it  is  rarely  necessar}'  to 
penetrate  the  process  to  that  extent  in  mastoiditis.  But  the  importance  of 
the  anatomical  relation  of  the  ujjper  part  of  the  facial  nerve  (as  shown  in 
Plates  XXXVI  to  XXXIX)  cannot  be  too  strongly  emphasized,  as  its 
position  is  such  and  its  protection  so  slight  that  in  simple  operations  on 
the  drum  or  on  the  contents  of  the  middle  ear,  or  the  faulty  direction  of 
the  chisel  in  opening  the  mastoid  antrum,  the  canal  may  be  opened  and  the 
nerve  injured  (abraded,  crushed,  incised,  or  severed),  thus  producing  most 
disagreeable  after-effects.  The  stapes  is  seen  once  more  lodged  in  the 
fenestrum  ovale  directly  below  the  course  of  the  nerve,  but  devoid  of  its 
muscle  on  account  of  removal  of  its  casing  of  bone  posteriorly. 

The  aditus  ad  antrum  I  indicated  by  arrow  in  Plate  XXX\Tin  or  passage 
leading  from  the  upper  part  (attic)  of  the  tympanum  to  the  antrum,  along 
which  the  infection  of  a  middle  ear  disease  so  often  travels  into  the  antrum, 
can  be  shown  bv  removing  a  sufficient  amount  of  bone  from  the  upper  and 
posterior  walls  of  the  bony  meatus  (Plate  XXXIX).  (This  is  one  of  the 
steps  in  the  Stacke-Schwartze  "radical  o])eration.'" )  When  this  is  done 
the  plate  of  bone  forming  the  roof  of  the  tympanic  cavity  (called  the  tegmen 
tympani)  is  seen;  that  portion  of  bone  forming  the  roof  of  the  antrum  is 
called  tegmen  antri.  The  tegmen  is  very  thin  (Vj  to  2  mm.)  in  most  skulls 
and  at  times  incomplete,  and  can  easily  be  eroded  by  the  acrid  discharge  of 
a  middle  ear  disease.  This  complication  often  leads  to  the  formation  of  an 
extradural  abscess  of  the  middle  fossa  of  the  skull  or  to  inflammation  of  its 
dural  lining,  which  in  time  may  lead  to  intradural  or  cerebral  abscesses  or 
to  inflammation  of  the  entire  arachnoid  or  pia  mater. 


ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR  131 

With  the  exposure  as  descrilied,  all  the  necrosed  or  diseased  bone  can 
be  removed,  which  in  itself  is  often  sufficient  to  check  an  inflammation  of 
the  meninges  or  brain  which  has  been  caused  by  the  necrosis. 

An  extradiu-al  abscess  can  be  drained  through  the  opening  made  in  the 
tegmen,  while  a  deep-seated  one  could  be  more  easily  reached  through  the 
opening  in  the  squamous  plate,  as  will  be  mentioned  farther  on  (Plates 
XXXVIII  and  XXXIX). 

On  removal  of  the  outer  wall  of  the  aditus,  as  mentioned,  the  projection 
formed  by  the  horizontal  semicircular  canal  is  seen  forming  a  part  of  the 
floor  and  inner  wall  of  the  aditus  (  Plate  XXXTX  ).  It  will  be  readily  under- 
stood how  easily  the  canal  can  be  opened  if  on  exposing  the  antrum  the 
chisel  is  directed  too  far  forward  or  downward  at  a  depth  greater  than 
lyi  cm. 

On  dislodging  the  facial  ner\e  from  its  groove,  the  inner  wall  of  the  aquae- 
ductus  Fallopii  is  shown  extending  from  the  upper  anterior  angle  of  the 
tympanum  backward  directly  below  the  h<.irizontal  semicircular  canal,  with 
the  fenestrum  ovale  beneath  it ;  it  then  bends  downward,  with  the  fenestrum 
rotundum  in  front  of  it,  and  reaches  the  stylomastoid  foramen  at  a  depth 
of  about  iy2  cm.  from  the  outer  surface  of  the  mastoid  process. 

On  removal  of  the  tympanic  plate  the  floor  of  the  tympanic  cavity  is  seen 
to  consist  of  bone  varying  in  thickness  from  J4  to  Yi  cm.  Frequently  this 
helps  to  form  the  outer  wall  of  the  jugular  fossa,  and  where  necrosis  of 
the  bone  or  intlanunation  of  the  communicating  veins  in  the  bone  has  taken 
place,  an  inflammation  or  thrombosis  of  the  bulbar  portion  of  the  jugiflar  vein, 
which  is  contained  in  the  fossa,  results. 

Continuing"  with  the  dissection  of  the  mastoid  process,  we  find  that  on 
removing  the  ledge  between  the  upper  and  lower  posterior  windows  (as 
shown  in  Plate  XXXVII)  and  making  them  contimious,  a  longer  stretch 
of  the  descending  limb  of  the  sigmoid  flexure  of  the  lateral  sinus  can  be 
exposed,  and  its  walls  more  readily  incised,  if  it  is  necessary  to  inspect  its 
interior  or  to  determine  its  contents.  By  inspecting  its  interior  you  can 
determine  if  an  adhering  throm1)us  exists  which  does  not  clog  the  entire 
lumen.  Incomplete  thrombi  are  more  frequent  where  the  sinus  enters  the 
jugular  vein  in  a  more  or  less  straight  line,  while  if  they  join  at  an  acute 
angle  the  thrombus  is  more  often  complete.  .\  coating  or  granulations  on 
the  outer  side  of  the  sinus,  or  necrotic  areas  in  its  wall,  make  the  presence 
of  a  thrombus  probable.  If  no  clot  is  present  in  such  a  case,  the  opening 
must  be  packed  with  gauze  and  equable  pressure  made,  by  means  of  a  gradu- 


132  ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

ated  conical  cuiiipress,  to  cnnlrol  the  licniDrrhage.  If  ihe  inner  wail  is  to  be 
inspected,  the  hemorrhage  must  be  controlled  by  packing  or  compressing 
the  sinus  at  both  ends.  If  a  clot  is  found,  this  must  be  removed  and  the 
ensuing  hemorrhage  controlled  as  just  mentioned.  If  the  entire  removal  of 
the  clot  is  not  successful,  an  extended  incision  must  be  made  above  or  below 
or  in  both  directions,  according  to  the  extension  of  the  clot,  so  that  complete 
patency  of  its  lumen  is  established  and  the  entire  sinus  can  be  inspected  f<jr 
possiljle  necrosis  of  its  wall. 

The  entire  course  of  the  sinus  can  be  ex])osed  alji.ive  by  an  incision  com- 
mencing at  the  upper  posterior  (piadrant  in  a  direction  upward  and  backward 
and  then  gradually  downward  until  it  reaches  the  external  occipital  protul^er- 
ance,  which  corresponds  on  the  inside  of  the  skull  to  the  torcular  Herophili 
(Plate  XXXVII).  The  bone  covering  it  can  be  removed  by  means  of  a 
chisel,  circular  saw,  or  drill,  and  the  dural  co\ering  incised  along  its  entire 
course,  if  this  should  l)e  found  necessary  in  order  to  remove  the  clot  or  in- 
fected matter  filling  the  canal,  or  to  excise  the  wall  itself  if  found  necrotic 
(Plate  XXXVIII). 

About  I  cm.  above  the  posterior  window  the  slit  leading  to  the  superior 
petrosal  sinus  can  be  seen.  Posteriorlv  the  opening  to  the  sinus  of  the  other 
side  is  visible,  and  somewhat  in  front  and  al)ij\e  this  the  longitudinal  sinus 
has  its  termination.  Along  the  entire  course  of  the  lateral  sinus,  slits  repre- 
senting the  entrance  of  cerebral  veins  can  be  seen.  Frequently  fibrous  bands 
are  also  found  stretching  across  the  lumen  and  forming  supports  to  main- 
tain the  patencv  of  the  canal  against  the  pressure  exerted  by  the  weight  of 
the  brain. 

Below  and  in  front,  corresponding  to  the  lower  posterior  window,  the 
sinus  will  be  seen  to  dip  in  toward  the  jugular  fossa,  forming  the  lower  limb 
of  the  sigmoid  flexure. 

If  the  svmptoms  and  physical  signs  of  the  case  make  probable  the  pres- 
ence of  an  extradural,  intradural,  or  cerebral  abscess,  especially  of  the  tem- 
poral lobe,  which  occurs  more  frequently,  or  the  presence  of  fluid  in  the 
ventricles,  a  puncture  of  the  brain  in  various  directions  can  be  made  through 
a  trephine  opening  in  the  scjuamous  portion  of  the  temporal  bone.  This  can 
be  readily  exposed  on  retracting  the  temporal  muscle  upward  after  removal 
of  its  fascia  (as  shown  in  Plates  XXXVII  and  XXXVIII).  On  removing 
the  button  of  bone,  a  branch  of  the  middle  meningeal  artery  is  frequently 
seen  traversing  the  space.  A  long  aspirating  needle  or  narrow-bladed  knife 
can  be  passed  into  the  brain  in  various  directions  until  the  presence  or  ab- 


ANATOMY  AND  SUR(;I-:RY  Ol-  NOSE  AND  EAR     133 

^ence  of  ])us  in  the  hratii  nr  excessive  accnnnilalinii  of  cerel)r(is])inal  lluiil 
in  the  \entricles  is  deteriiiined  and  li>caleil.  If  pu^  is  fnund  and  tlie  lre])liinc 
opening  is  not  of  sufficient  size  to  afford  proper  drainage,  the  temporal  muscle 
can  be  still  furtlier  detached  and  all  the  soft  parts  be  retracted  upward  and 
forward  sd  that  the  opening  can  be  enlarged  in  various  directions. 

If  the  diagnosis  of  abscess  is  positive  Ijeforehand,  and  the  cerebral  cavity 
is  to  be  opened  in  coml)ination  with  the  radical  ear  "iicratiim,  a  quadrilateral 
osteoplastic  flap  is  made  of  the  scjuamous  imrtirm  of  the  temporal  l>i:ine  and 
turned  forward  as  mentioned   farther  on. 

If  on  incising  the  lateral  sinus  in  tlie  upper  posterior  window  (as  shown 
in  Plate  NXXIX)  a  suspected  sinus  affection  is  not  found  to  exist,  but  the 
train  of  symptoms  points  to  the  presence  of  a  serious  complication  in  this  re- 
gion, the  dura  of  the  cerel)ral  or  cereliellar  lobes  can  be  exposed  by  a  single 
or  double  "trap-door"  incision,  the  course  of  the  lateral  sinus  serving  as  a 
median  line  from  wbicii  the  osteoplastic  flaps  can  lie  cut  above  and  Iselow. 
The  incisiun  in  tlie  dura  mater  should  be  luade  on  three  sides  only,  and  should 
leave  a  sufticient  margin  to  which  the  flap  can  be  sewed  wlien  rejilaced  subse- 
quently. 

Through  tiiis  exposure  the  occipital  con\olutions  of  the  cerebrum,  the 
entire  half  of  the  tenturium  cerebelh,  and  the  posterior  fossa  of  the  skull, 
with  its  cereliellum,  can  lie  inspected,  and  extradural,  intradural,  or  lirain 
abscesses  can  be  incised  and  drained.  A  simple  and  tolerably  accurate  method 
of  locating  the  horizontal  limb  of  the  lateral  sinus,  without  the  aid  of  the 
mastoid  quadrants,  is  Chipault's  method,  which  consists  in  taking  a  point 
95  per  cent,  of  the  distance  between  the  nasion  and  inion  and  j<iining  it  by  a 
straiglit  line  with  tiie  retroorl)it;d  tubercle.  The  [losterior  half  represents 
the  course  of  the  horizontal  linil)  of  the  sinus  (see  sketch  under  technic, 
below ) . 

To  afford  a  sufficient  exposure  fiir  a  very  deep  dissection  of  the  petrous 
portion  of  the  temporal  bone,  it  is  necessary  to  remove  a  plate  of  lione  from 
above  the  ear,  preferably  quadrilateral  in  shape,  about  4  cm.  long  and  3  cm. 
wide,  to  include  the  portion  of  the  squamous  plate  lying  over  the  posterior 
half  of  the  zygomatic  arch,  and  reaching  back  as  far  as  the  middle  of  the 
mastoid  process.  The  flap,  containing  skin,  nuiscle,  and  bone,  and  nourished 
by  a  branch  of  the  temporal  artery,  is  turned  forward  (Plate  XL). 

P)y  retracting  the  dura  from  the  upper  surface  of  the  petrous  bone,  re- 
sistance will  be  met  with  in  front,  where  the  middle  lueningeal  artery  emerges 
from  the  foramen  spinosum.     At  a  depth  of  about  3  cm.  from  the  exterior 


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135 


J36  ANATOMY  AND  SL'RCiERV  OF  NOSE  AND  EAR 

of  the  skull  the  carotid  artery  can  be  exposed  on  removal  of  its  bony  canal 
from  above.  The  cochlea  will  be  found  situated  in  the  angle  formed  by  the 
artery  as  it  bends  inward  and  forward  frum  below,  while  the  Eustachian 
tube,  with  its  gallery  containing  the  tenstjr  t\'m])ani  muscle,  hugs  it  anteri- 
orly. The  opening  of  the  Eustachian  tube  in  the  upjier  anterior  angle 
of  the  middle  ear  is  directly  in  front  and  external  to  the  ascending  limb 
of  the  artery.  In  cases  where  but  a  tliiu  la\er  of  bone  covers  the  artery,  or 
where  the  bone  is  entirely  absent  in  this  situation,  the  artery  can  be  seen 
pulsating  on  examining  the  middle  ear,  and  its  puncture  by  a  paracentesis 
needle,  carried  too  deeplv,  is  possible.  Here,  too,  necrosis  of  the  inner  wall 
of  the  tympanic  cavity,  forming  the  bony  canal  of  the  artery,  can  produce 
a  destructive  process  in  the  wall  of  the  vessel  and  cause  fatal  hemorrhage 
if  not  ligated  l)elow  in  time.  The  artery  is  at  a  depth  of  about  2  cm.  from  the 
auditory  process,  and  has  the  jugular  vein  directly  Ijehind  it  and  somewhat 
to  its  outer  side.  In  all  the  previous  dissections  the  facial  nerve  has  been  ex- 
posed only  from  the  anterior  superior  angle  of  the  tympanum.  If  we  follow 
the  course  of  the  nerve  in  the  ai|Uc'eductus  Fallo])ii  as  it  emerges  from  the 
internal  auditorv  meatus  and  passes  forwartl  between  the  cochlea  and  vesti- 
bule, it  forms  an  angle  of  45  with  the  long  axis  of  the  skull  (Plates  NL  and 
NLIII).  As  it  enters  the  middle  ear  it  turns  outward  and  backward,  form- 
ing an  elbow  from  the  point  of  which  the  superficial  petrosal  nerve  is  given 
off.  The  latter  passes  inward  and  forward  through  the  hiatus  Fallopii  along 
the  upper  surface  of  the  petrous  b(ine  initil  it  reaches  the  middle  lacerated 
foramen. 

The  base  of  the  cochlea  is  formed  by  the  anterior  wall  of  the  internal 
auditory  meatus:  its  apex  juts  against  the  Eustachian  tul:)e.  To  its  inner  side 
is  the  carotid  canal :  to  its  (juter  the  aqu.'eductus  Fallo])ii,  with  the  facial  nerve 
above  and  the  vestibule  below. 

The  vestibule  is  seen  at  the  outer  side  of  the  facial  canal  with  the  hori- 
zontal semicircular  canal  coming  from  it  externally,  and  the  perpendicular 
semicircular  canal  superiorly. 

The  exposure  of  the  sigmoid  flexure  of  the  lateral  sinus  has  been  brought 
about  by  the  removal  of  almost  the  entire  mastoid  process  (Plate  XLl  In 
this  procedure  injury  to  the  facial  nerve  must  be  avoided.  This  nerve  emerges 
from  the  stylomastoid  foramen,  at  the  depth  of  about  1^2  cm.  from  the  an- 
terior border  of  the  process,  and  when  located  the  nerve  should  be  gently 
drawn  forward,  as  the  jugular  -s-ein  will  be  found  ^2  cm.  to  its  inner  side. 
The  nerves  accompanying  the  sinus  through  the  posterior  lacerated  foramen 


ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR     137 

are  covered  by  it  so  that  llicy  need  not  l.)e  considered.  'I"he  foramen 
magnum  lies  .13/  cm.  to  its  inner  side  and  posteriorly.  When  the  sinus  is 
opened,  slits  of  the  inferior  petrosal  and  occipital  sinuses  and  the  condyloid 
vein  can  be  seen  where  these  vessels  enter  the  jugular  vein.  The  jugular 
fossa,  which  contains  the  bulb  of  the  vein,  varies  in  shape  in  dilTerent  skulls 
and  on  both  sides  of  the  same  skull.  At  times  it  is  vaulted  and  smonth  and 
approximates  the  floor  of  the  middle  meatus,  but  it  may  lie  low,  contracted, 
and  traversed  with  irregular  ridges.  The  former  conditi(jn  is  considered  a 
predisposing  cause  in  thrombosis  of  the  bulb  of  the  jugular  vein  (m  account  of 
the  more  intimate  relation  of  this  part  with  the  middle  ear ;  and  the  same 
is  also  claimed,  on  account  of  the  more  tortuous  course  the  blood  stream  is 
subjected  to.  Infectious  material  might  pass  along  the  entire  route  of  the 
sinus  without  producing  any  harm,  but  at  the  jugular  fossa  the  flow  of  venous 
blood  is  checked,  producing  currents  (whirlpool)  which  favor  the  formation 
of  a  thrombus,  on  account  of  the  greater  liability  to  injury  and  infection 
which  the  wall  of  the  vein  is  subjected  to. 

If  the  bulb  of  the  vein  alone  is  involved,  the  jugular  should  be  ligated  be- 
fore the  sinus  and  Ixill)  are  incised ;  but  if  the  infection  has  gone  farther,  and  a 
cord-like  strand  on  the  side  of  the  neck  indicates  an  extensive  thrombus  of  the 
vein,  ligation  should  not  be  performed. 

To  demonstrate  the  intimate  relation  between  the  ear  and  the  cerebral 
cavitv,  a  transverse  section  <if  the  head  through  the  center  of  the  middle  ear 
has  been  made  (Plate  NLl).  The  external  auditory  canal  is  seen  slanting 
upward  and  inward,  its  outer  half  lined  with  short  hairs  directed  outward. 
The  external  meatus  is  separated  from  the  middle  ear  aljove  by  a  plate  of 
bone  which  forms  the  outer  wall  of  the  attic,  while  below  is  the  tympanic 
membrane,  with  the  manubrium  and  processus  brevis  of  the  malleus  attached 
to  it.  The  roof  of  the  tympanum  has  a  thin  plate  of  bone,  the  tegmen  tympani, 
separating  it  from  the  cerebral  cavity. 

A  section  of  this  kind  demonstrates  the  intimate  relati<in  between  the  two 
parts  and  shows  how  readil\-  an  erosion  or  a  fissure  in  the  partition  may 
lead  to  serious  involvement  of  the  lirain  and  its  covering  when  the  middle 
ear  is  inflamed. 

On  the  inner  wall  of  the  t\'mpanic  cavity  can  be  seen,  from  al.)o\-e  down- 
ward, first,  the  projection  made  liy  the  aqureductus  Fallopii  with  its  facial 
nerve:  underneath  this  the  tendon  of  the  tensor  tympani  muscle  emerging 
from  the  upper  part  of  the  Eustachian  tube.  Directly  behind  it  and  on  the 
same  level  is  the  fenestrum  ovale,  containing  the  stapes.     From  here  on  down- 


PLATE    XLI 


Cross-section  of  right  side  of  head,  showing  external  meatus,  separated  from  middle 
ear  by  outer  wall  of  atticus  al)Ove  and  tympanic  membrane  below.  In  the  middle 
ear  are  seen  the  tegmen  tympani,  the  ossicles,  the  tensor  tympani  muscle,  and 
projections  of  the  aqu;eductus  Fallopii.  with  facial  nerve  above  and  first  turn  of 
cochlea  below.  Deep  in  the  bone  the  cochlea.  Below,  the  bulb  of  the  jugular  vein. 


138 


Tegmen  tympani 

Malleus 

Attic 

Outer  wall  of  attic 

Processus  brevis 

Manubrium 

Ext.  uud.  meatus 

Tympanic  membrane 

Tympanum 

Promontorium 


Incus 

Tensor  tympani  muscle 

Facial  nerve 

Cochlea 
Stapes 


Inferior  petrosal  sinus 
Lateral  sinus 


Jugular  vein 


139 


Protuberance  of  perpendicular  (sup.)  semicircular  canal 
Bristle  in  horizontal  semicircular  canal 

Internal  auditory  meatus 

Facial  nerve 

Auditory  nerve 

Bristle  in  perpendicular  (sup.)  semicircular  canal 


Post,  condyloid  vein 
Inferior  petrosal  sinus 


X'estibule 

Aditus  ad  antrum 

Horizontal  (ext.)  semicircular  canal 

Post,  wall  of  tympanum 

Post,  wall  of  external  meatus 

Lateral  sinus 

Jugular  vein 


140 


ST.  iOHNS 
KEDICAL  Lie'./ 


PLATE    XLll 


Cross-section  of  left  side  of  head,  i  cm.  behind  previous  section.  .\  small  portion  of 
the  posterior  wall  of  e.xternal  meatus  is  seen.  Internal  to  this,  the  tegmen,  aditus 
ad  antrum,  projections  of  external  semicircular  canal  and  posterior  wall  of  middle 
ear.  The  vestilnile  shows  bristles  coming  from  the  superior  and  e.xternal  semi- 
circular canal.  The  internal  meatus  contains  the  facial  and  auditory  nerves.  Below 
is  seen  the  jugular  vein  with  openings  of  the  posterior  condyloid  vein  and  inferior 
petrosal  sinus. 


141 


142  ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

ward  tlie  prunmnturium,  representing'  llie  be.^nnning  of  the  cochlea,  bulges 
outward,  forming  a  recess  with  the  floor  of  the  meatus.  The  floor  consists 
of  a  varied  thickness  of  Ijone  and  occasionally  communicates  with  the  jugular 
fossa  through  fissures  or  small  lymph  channels. 

The  cavity  of  the  tympanum  contains  the  ossicles.  Of  these  the  malleus 
is  anterior,  with  its  head  in  the  attic,  the  tendon  of  the  tensor  tympani  muscle 
attached  to  its  neck,  and  the  suspensory  ligament  extending  from  the  tegmen 
to  its  head.  Its  short  process  projects  outward,  throwing  the  upper  part  of 
the  membrane  into  folds,  and  the  manubrium  extends  downward,  with  its 
tip  turned  outward,  attached  to  the  midpoint  of  the  tympanic  membrane. 
The  incus  is  located  posterior  to  the  malleus,  with  its  body  in  the  attic,  its  short 
process  in  the  aditus,  and  its  long  process  projecting  downward  and  articu- 
lating with  the  head  of  the  stapes.  The  stapes  is  lodged  in  the  fenestrum 
ovale,  with  the  stapedius  muscle  attached  to  its  neck  posteriorly,  and  lies  hori- 
zontallv  and  at  right  angles  both  to  the  malleus  and  incus. 

Internal  to  the  middle  ear  and  set  in  tlie  most  compact  part  of  the  petrous 
bone  are  the  spiral  turns  of  the  cochlea,  with  the  apex  pointing  out  and  for- 
ward and  the  base  butting  against  the  wall  of  the  internal  auditory  meatus. 

Below  the  bony  framework  surrounding  the  ear  and  lying  somewhat  to 
the  inner  side  of  the  middle  ear  is  the  bulb  of  the  jugular  vein,  in  the  jugular 
fossa. 

A  transverse  section  of  the  head,  about  i  cm.  behind  the  one  just  described 
(Plate  XLII),  shows  only  a  small  portion  of  the  posterior  wall  of  the  external 
meatus,  and  parts  of  the  middle  ear  and  inner  meatus  corresponding  to  that 
level.  Above,  a  thin  plate  of  bone  is  seen  separating  the  cerebral  cavity  from 
the  aditus  ad  antrum.  Tlie  aditus,  shaped  like  an  inverted  pyramid,  has  the 
protrusion  of  the  horizontal  semicircular  canal  forming  a  part  of  its  floor  and 
inner  wall.  Below  this  is  seen  the  posterior  wall  of  the  middle  ear  proper, 
made  up  of  irregular,  open  bony  cells  covered  with  a  delicate  mucous  mem- 
brane, which  lines  the  tympanum  and  communicating  cavities.  Internal  to 
these  parts  can  be  seen  the  interior  of  the  vestibule,  with  the  openings  of  the 
semicircular  canals  on  its  outer  side.  Anteriorly,  the  anterior  ends  of  the 
superior  or  vertical  and  the  external  or  horizontal  canals  have  a  common 
opening,  while  posteriorly  the  posterior  end  of  the  superior  and  the  upper 
end  of  the  posterior  canals  have  a  common  opening.  The  openings  of  a  hori- 
zontal canal  lie  on  the  same  plane,  while  those  of  the  posterior  canal  lie  one 
above  and  the  other  below  the  posterior  opening  of  the  horizontal  canal 
(See  also  Plate  XLIV). 


ANATOMY  AND  SURGE  in'  Ol"  NOSE  AND  EAR  143 

Tlie  exterior  of  the  superior  or  \ertieal  semicircular  caual  forms  a  slii^ht 
protulieranee  on  the  upper  surface  of  the  ])etrous  Ijoiie  corresponding  to  its 
course,  from  in  front  and  externally,  hack  and  internally. 

Internal  to  the  vestibule  is  the  internal  auditory  meatus  containing  the 
facial  and  auditory  nerves :  the  facial  ahove,  directed  toward  the  aqu;cductus 
Fallopii,  and  the  auditory  helovv,  about  to  enter  the  \-estibule  and  cochlea,  the 
direction  now  considered  l^eing   fmui  the  brain  outward. 

The  bull)  of  the  jugular  vein  is  seen  in  the  fossa,  and  several  slits  indicate 
the  entrance  of  emissary  veins. 

On  inspecting  the  middle  and  posterior  fossa  of  tlie  skull,  when  the  brain 
has  Ijeen  raised  from  its  bed,  and  reuKjving  the  dura  mater  <iver  the  petrous 
bone  in  the  middle  fossa,  the  following  structures  can  be  exposed  by  chisel- 
ing the  bone  (Plate  XLIII)  :  Externally,  the  mastoid  antrum;  in  front  of 
it,  and  coming  from  the  middle  ear,  the  aditus  ad  antrum.  The  horizontal 
semicircular  canal  is  seen  helping  to  form  the  inner  wall  and  floor  of  this 
passage.  The  middle  ear  is  antericjr  and  internal  to  the  antrum,  and  presents 
the  malleus  and  incus  in  the  attic  and  the  tympanic  membrane  deep  down, 
forming  its  outer  wall.  The  tensor  tympani  muscle  is  seen  in  its  groove  in 
the  upper  part  of  the  Eustachian  tube,  passing  outward  and  backward,  and 
becoming  inserted  into  the  neck  of  the  malleus.  The  facial  nerve  is  seen  as 
it  disappears  at  the  upper  anterior  angle  of  the  tympanum,  forming  an  elbow 
from  the  angle  of  which  the  superior  petrosal  nerve  is  given  off.  Posterior  to 
this  point  it  lies  Ijetween  the  cochlea,  which  is  on  its  inner,  and  the  vestibule, 
which  is  on  its  outer  side.  In  the  internal  auditory  meatus  it  lies  above  the 
auditory  nerve,  and  in  the  posterior  fossa  to  its  outer  side. 

The  vestibule  shows  the  groove  of  the  superior  semicircular  canal  and  the 
o])enings  of  the  other  two  canals.  The  cochlea  lies  in  the  back  part  of  an 
angular  recess  formed  by  the  bend  in  the  carotid  canal  as  it  ascends  from  the 
base  of  the  skull,  and  has  the  tympanic  cavitv  and  acjuaeductus  Fallopii,  with 
the  facial  nerve  to  its  outer  side.  The  Eustachian  tube  is  in  front,  the  internal 
auditory  meatus  behind,  and  the  compact  bone  over  the  carotid  canal  to  its 
inner  side. 

The  carotid  canal  has  the  general  direction  of  the  petrous  bone  inward 
and  forward,  with  the  luistachian  tube  immediately  in  front  of  it,  the  super- 
ficial petrosal  nerve  coursing  over  it  as  it  passes  from  the  hiatus  Fallopii  to 
the  middle  lacerated  foramen  and  compact  bone  behind  it.  As  it  ascends  from 
the  base  of  the  skull  it  is  directly  internal  to  the  inner  wall  of  the  middle  ear. 
As  the  canal  passes  inward  toward  the  middle  lacerated  foramen,  the  Gas- 


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144 


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Malleus 

Tympanic  membrane 

Long  process  of  incus 

Short  process  of  incus 

Aditus  ad  antrum 

Horizontal  semic.  canal 

Mastoid  antrum 

Facial  nerve 

Perpendicular  sup.  semJc.  cana! 

Openings  of  ext.  canal 

Openings  of  post,  semic.  canai 

Superior  petrosal  sinul 


Sigmoid  flexure 
r  ateral  sinus 


Tensui  lym|jani  muscle 
Aliddle  meningeal  artery 

Suijerficial  petrosal  nerve 

(-'av:.'rnGUs  sinus 
Gasserian  ganglion 


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Carotid  canal 

Cochlea 

Auditory  nerve  in  int. meatus 

Apertura  scalse  vestibulse  cochleae 

Internal  auditory  meatus 

Auditory  nerve 

Facial  nerve 


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147 


148  AXATO:\IY  AXD  Sl'RCERY  OF  NOSE  AND  EAR 

serian  ganglion  lies  over  it,  in  a  depression  at  the  inner  end  of  the  superior 
surface  of  the  petrous  bone. 

The  middle  meningeal  artery  can  I)e  seen  through  the  dura  mater  as  it 
emerges  from  the  foramen  spinosum,  and  sends  its  anterior  and  posterior 
hranches  (jutward  and  upward,  grooving  the  skull  in  its  course.  The  superior 
petrosal  sinus  is  seen  running  along  the  superior  posterior  border  of  the  petrous 
bone,  joining  the  lateral  with  the  cavernous  sinus. 

The  lateral  sinus  extends  from  the  torcular  Herophili  behind  to  the  jugu- 
lar foramen  in  front.  .\t  the  torcular  it  communicates  with  the  lateral  sinus 
of  the  other  side,  the  longitudinal  sinus  aljove,  and  the  occipital  below.  The 
part  which  descends  from  the  horizontal  limb  to  the  jugular  foramen  is  known 
as  the  sigmoid  flexure  of  the  lateral  sinus.  It  forms  an  ellxiw  with  the  hori- 
zontal limb,  and  passes  downward  and  inward  in  the  dee])ly  grooved  bone 
until  it  reaches  the  posterior  lacerated  foramen,  where  it  is  j(jined  by  the 
inferior  petrosal  sinus  and  the  posterior  condyloid  \ein  to  form  the  internal 
jugular  vein.  It  is  accompanied  bv  the  ninth,  tenth,  and  eleventh  nerves, 
which  ha\e  sejiarate  sheaths  of  dura  mater. 

If  a  vertical  anteroposterior  section  of  the  head  is  made  to  pass  directly 
through  the  tympanic  cavity  (as  seen  in  Plate  XLI\')  the  following  points 
of  interest  can  Ije  shown:  Between  the  tympanic  and  cerebral  cavities  the 
tegmen  tympani,  on  the  inner  wall  of  the  middle  ear  which  is  covered  by 
delicate  mucous  membrane,  the  orifice  of  the  Eustachian  tube  and  the  canal 
for  the  tensor  tympani  muscle  (processus  cochlear]  formis )  ;  the  latter  has 
an  orifice  at  its  posterior  end,  and  transmits  the  tendon  of  the  tensor  tympani 
muscle;  behind  this  the  a<|ua;ductus  Fallopii,  with  the  facial  nerve  passing 
back  and  down,  around  the  fenestrum  ovale ;  underneath  this  the  promon- 
torium,  with  the  fenestrum  rotundum.  Projecting  from  the  floor  downward 
is  the  styloid  process.     Below  this  is  a  section  of  the  jugular  vein. 

Above  and  posterior  to  the  middle  ear  is  the  body  of  the  petrous  bone 
traversed  by  the  semicircular  canals.  The  openings  of  the  horizontal  or  ex- 
ternal one  are  above  and  parallel  to  the  facial  nerve :  the  vertical  or  superior 
passes  from  in  front  upward  and  posteriorly ;  the  posterior  canal  is  situated 
behind,  with  one  opening  above  and  the  other  below  the  posterior  opening  of 
the  horizontal,  as  mentioned  previously. 

.\t  the  upper  posterior  border  of  the  petrous  tone  is  the  superior  petrosal 
sinus.  .\.  part  of  the  sigmoid  flexure  of  the  lateral  sinus  is  seen  at  a  point 
where  the  occipital  meets  the  petrous  bone.  The  opening  of  the  lateral  sinus 
is  seen  behind  at  a  point  where  the  tentorium  cerebelli  meets  the  dural  lining 


AXATOMV  AX  I)  SIRCERV  OF  NOSE  AND  EAR  149 

of  tlie  occipital  hone.  The  leiitoriuni  is  seen  separating  cerehral  from 
cerehellar  convolutions. 

In  recapitulating  the  (iperali\e  techni(pK'  mentioned  in  the  foregoing  pages 
five  separate  procedures  may  be  described : 

First,  "radical"  exposure  of  the  middle  ear;  second,  exposure  of  the 
mastoid  antrum:  third,  exposure  of  the  mastoid  antrum  and  cells  and  lateral 
sinus  ("mastoid  (|uadrants")  ;  fourth,  exposure  of  the  temporal  lohe  of  the 
brain  and  middle  fossa  of  the  skull;  fifth,  exp(jsure  of  the  occipital  lohe  of 
the  brain,  tentorium  cerebelli,  cerebellum,  and  posterior  fossa  of  the  skull. 

For  the  "radical"  exposure  of  the  middle  ear  an  incision  is  made  ^  to 
I  cm.  behind  the  attachment  of  the  auricle  extending  from  above  the  ear  down- 
ward to  the  tip  of  the  mastoid  process  (  Plate  XNNIII  ).  Above  the  temporal 
ridge,  which  corresponds  in  height  to  the  upper  wall  of  the  outer  meatus 
(Plate  XXXIV),  the  incision  should  be  through  skin  and  superficial  fascia 
alone,  leaving  the  temporal  muscle  intact.  Below  the  ridge  it  should  pass 
directly  to  the  bone.  The  tissues  are  dissected  forward  and  the  periosteum 
elevated  until  the  bony  meatus  is  reached.  To  avoid  possible  necrosis  of 
the  tympanic  plate  the  soft  parts  of  the  posterior  and  upper  wall  of  the  soft 
meatus  alone  should  first  be  detached  with  an  elevator  and  then  incised  by 
means  of  a  thin-bladed  knife  near  the  tympanic  membrane  and  held  against 
the  anterior  wall  with  a  long,  narrow  retractor;  or,  if  the  tympanic  plate  is 
to  be  chiseled  away,  the  anterior  and  lower  walls  can  be  cut  also  and  the 
entire  funnel  of  soft  tissues  drawn  out  of  the  bony  canal  and  retracted  with 
the  auricle.  The  tympanic  membrane  is  now  cut  from  its  ring  of  bone  and 
removed  with  the  malleus  after  the  attachment  of  the  tensor  tympani  muscle 
has  been  severed.  With  a  chisel,  or  preferably  a  burr  drill,  the  outer  wall 
of  the  attic,  which  corresponds  to  the  inner  part  of  the  upper  wall  of  the 
external  meatus,  is  then  removed  until  the  roof  of  the  attic  is  continuous  with 
the  upper  wall  of  the  external  meatus  (Plates  XXXVI  and  XXXVII).  If 
this  does  not  give  a  sufficient  exposure  the  tMupanic  plate  can  be  chiseled 
away  as  far  as  the  styloid  process  (Plate  XXXVIII).  After  removal  of  the 
incus  (Plate  XXXA^II),  which  should  be  cautiously  done,  so  as  not  to  dis- 
lodge the  stapes  from  the  fenestrum  ovale,  a  probe  should  be  passed  through 
the  aditus  into  the  antrum,  and  the  bone  chiseled  or  drilled  away  external 
to  it  (Plates  XXXA'III  and  XXXIX).  The  interior  of  the  cavities  are  now 
curetted  and  smoothed,  care  Ijeing  taken  not  to  open  the  aqureductus  Fallopii 
and  horizontal  semicircular  canal,  nor  to  dislodge  the  stapes.  If  the  tegmen  is 
necrosed,  this  should  be  removed,  but  puncture  of  the  dura  mater  should 


I50  ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR 

be  avoided.  i\n  extradural,  intradural,  (ir  cerebral  abscess  can  be  located  or 
drained  through  this  ajjcrture,  but  a  trephine  opening  through  the  scjuanious 
plate  of  the  temporal  bone,  after  the  temporal  muscle  has  been  detached  and 
drawn  upward,  is  better  for  this  purpose  (Plate  XXXVIII).  The  latter  will 
also  suffice  for  aspirating  the  lateral  ventricles  for  excessive  accumulation  of 
cerebrospinal  lluid.  If  a  deep  dissection  of  the  temporal  bone  is  necessary, 
especially  if  the  upi)er  surface  of  the  petrous  bone  is  to  be  exposed,  or  if  an 
aljscess  is  not  drained  sufficiently  through  the  trephine  opening  just  mentioned, 
a  quadrilateral  osteoplastic  flap,  3  cm.  wide  and  4  cm.  long,  with  its  base 
anteriorly,  should  lie  made  to  inchide  the  portion  of  squamous  bone  lying 
over  the  posterior  half  of  the  zygomatic  arch,  and  reaching  back  as  far  as 
the  middle  of  the  mastoid  process  (Plate  XL).  If  the  upper  portion  of  the 
petrous  bone  is  to  be  chiseled,  the  dura  mater  should  be  elevated  gently  and 
the  brain  retracted  with  a  broad.  l>lunt  retractor.  More  room  can  I)e  obtained 
b\'  incising  the  dura  and  permitting  some  cerebrospinal  lluid  to  escape.  This 
should  not  be  done  if  pus  is  present  or  if  the  brain  or  its  coverings  have  not 
already  been  attacked.  After  the  tissues  have  been  replaced  to  their  original 
position  and  sutured,  an  opening  is  left  sufficiently  large  for  drainage,  and 
the  wound  packed  with  gauze  until  epidermization  of  the  exposed  parts  is 
complete. 

To  expose  the  mastoid  antrum  an  incision  is  made  J<2  to  i  cm.  behind  the 
auricle,  extending  from  a  point  corresponding  in  height  to  the  upper  wall 
of  the  external  meatus  downward  to  the  tip  of  the  mastoid  process  (see  cross 
on  Plate  XXXIII).  The  tissues  are  dissected  forward  and  the  periosteum 
elevated  until  the  suprameatic  spine  can  be  felt  with  the  finger  or  an  instru- 
ment. Keeping  below  the  temporal  crest,  an  opening  is  made  with  a  chisel 
or  burr  drill  i  cm.  behind  the  suprameatic  spine.  The  instrument  should  be 
directed  forward,  inward,  and  slightly  upward,  corresponding  to  the  direction 
of  the  external  meatus  to  a  depth  of  i  to  2  cm.  When  the  instrument  has 
penetrated  deeper  than  ij i  cm.,  care  must  be  taken  not  to  open  the  horizontal 
semicircular  canal  or  aquseductus  Fallopii.  \\  hen  the  antrum  has  been 
reached,  granulations  or  irregular  bony  ridges  should  lie  removed  by  means 
of  a  curette,  care  being  taken  to  avoid  piercing  the  tegmen  antri  above  or 
the  bone  behind  which  separates  the  antrum  from  the  lateral  sinus.  If  the 
latter  be  exposed  no  harm  need  necessarily  result,  but  if  punctured,  the  hemor- 
rhage must  be  controlled  by  packing  the  bony  wound  with  a  graduated  gauze 
tampon.  When  the  antrum  is  clean  and  smooth  the  parts  are  replaced  and 
sutured,  leaving  an  opening  for  drainage,     ^^'hen  the  cavity  is  again  in  a 


ANATOMY  AND  SURGERY  OF  NOSE  AND  EAR     151 

healthy  condition  the  opening  will  close  by  granulation,  or  a  small  plastic 
operation  will  be  required  to  effect  this. 

If  the  lateral  sinus  is  to  be  exposed  with  the  antrum  and  mastoid  cells, 
the  mastoid  process  should  be  divided  into  four  quadrants,  as  described  pre- 
viously (Plates  XXXV  to  XXXVII).  The  anterior  superior  quadrant  is 
opened  first  with  the  instrument  directed  as  mentioned  in  the  previous  opera- 
tion, and  the  antrum  cleaned  and  packed.  Next,  the  two  lower  quadrants 
should  be  opened  and  evacuated.  After  packing  these  to  prevent  inflamma- 
tory discharges  from  spreading,  the  upper  posterior  quadrant  should  be  en- 
tered and  the  lateral  sinus  exposed.  Here  the  instrument,  preferably  a  burr 
drill,  should  be  directed  straight  in.  Palpation  of  the  sinus  must  be  performed 
very  carefully,  in  order  not  to  dislodge  adherent  or  incomplete  thrombi.  In 
such  a  case,  aspiration  with  a  hypodermic  syringe  might  show  blood  and 
lead  to  an  erroneous  diagnosis,  so  that  an  exploratory  incision  is  safer.  For 
this  purpose  the  lower  posterior  ijuadrant  should  bu  drilled  suHiciently  deep 
to  expose  the  sinus  below,  and  the  ledge  between  the  upper  and  the  lower  quad- 
rant should  be  removed  in  order  to  make  them  continuous. 

To  expose  the  entire  sigmoid  flexure  of  the  lateral  sinus  and  the  bulb 
of  the  jugular  vein,  the  lower  portion  of  the  mastoid  process  must  be  removed 
(Plate  XL).  The  facial  nerve  should  lie  located  and  exposed  to  its  exit 
at  the  stylomastoid  foramen,  and  the  spongy  bone  between  it  and  the  sinus 
chiseled  away.  PosteriorK-  the  foramen  magnum  must  be  avoided.  If  the 
thrombus  is  still  confined  to  the  upper  portion  of  the  jugular  vein,  ligation 
should  be  performed  below  this  point  before  the  sinus  is  incised. 

If  the  horizontal  linil)  of  the  sinus  is  to  be  exposed,  an  incision  from  the 
upper  posterior  quadrant,  first  upward  and  backward,  and  then  downward 
and  backward  toward  the  external  occipital  protuberance,  is  to  be  made 
(Plates  XXXVII  and  XXXVIII).  A  strip  of  bone  is  then  removed  by 
means  of  a  chisel,  circular  saw,  or  drill,  and  the  sinus  incised  to  the  extent 
of  the  clot.  Hemorrhage  is  to  be  controlled  with  gauze  strips  or  compresses, 
the  former  to  be  introduced  directly  into  the  lumen :  or,  if  this  is  insufficient, 
compression  should  be  applied  to  the  external  surface  of  the  sinus  after  de- 
taching it  from  its  bony  casing.  The  parts  are  subsequently  replaced  and 
sutured,  a  sufficient  opening  being  left  for  drainage. 

To  expose  the  occipital  lobe  of  the  brain,  the  cerebellum,  or  posterior  fossa 
of  the  skull,  a  single  or  double  "trap-door"  incision  is  made  above  and  below 
the  lateral  sinus  (Plate  XXXIX).  To  locate  the  latter,  Chipault's  method  can 
be  applied.     It  consists  in  taking  (;5  per  cent,  of  the  distance  between  the 


152  ANATOMY  AXD  SURGERY  OF  NOSE  AND  EAR 

PLATE   XLV 

,45  Precentral  Sulcus 

55  Rolandic  Fissure 


Nasion A.  \     V^^r^^^'^^l        i^'-^'V,  ,         1 — \ — ^0  Sylvian  Fissure 


Retro-Orbital, 
Tubercle  "l^       ^  '■^;~^.,^      ^--^^^^^^  |  ''~~~~S/ — -80°  Superior  Tempor< 

sphenoidal  Fissure 


95  Lateral  Sinus 


Chipault's  method  of  Iiraiii  localization. 

na'^^iun  and  inion,  and  jtiining  tliis  point  with  tlie  retruorbital  tnl)ercle.  The 
posterior  half  of  tlie  line  represents  the  horizontal  limb  of  the  lateral  sinus. 

The  incision  through  the  bone  is  made  by  means  of  a  circular  saw,  a  drill, 
or  a  trephine  and  Gigli's  wire  saw.  The  base  of  the  bon\-  tiap  is  to  be  nicked 
on  either  side  with  the  chisel,  so  that  the  bone  will  break  off  in  a  straight  line 
when  pried  open  with  the  elevator.  The  dura  is  to  be  incised  in  the  same 
direction  as  the  outer  flap,  a  sufficient  margin  being  left  if  the  condition  found 
permits  subsequent  suturing. 

Other  points  of  interest  in  cranial  topography  are  located  by  the  same 
method  just  mentioned  (Chipault's),  to  wit:  A  point  80  per  cent,  of  the 
distance  between  the  nasion  and  inion  joined  with  the  retroorbital  tubercle 
represents  the  course  of  the  parietooccipital  fissure.  A  point  70  per  cent,  the 
distance  of  the  same  sagittal  line  joined  with  the  tubercle  represents  the  course 
of  the  fissure  of  Sylvius.  If  the  latter  be  divided  into  tenths,  and  the  junc- 
tion of  the  third  and  fourth  tenth  be  joined  with  the  35  per  cent,  point  on  the 
longitudinal  line,  the  course  of  the  Rolandic  fissure  is  shown:  and  if  the 
junction  (jf  the  second  and  thirtl  tenth  on  the  Sylvian  line  be  joined  with 
the  45  per  cent.,  the  precentral  fissure  is  indicated.  The  middle  meningeal 
artery  crosses  between  the  second  and  third  tenths  of  the  three  primary  lines. 


INDEX 


INDEX 


Adenoids,  cause  of,  i6  Exposure    of    lateral    sinus,    123,    131, 

Aditus  ad  antrum,  130,  131,  142,  143  132,   151 

Air  pressure,  effects  of,  on  respiratory  Exposure  of  mastoid  antrum,  iii,  121, 

tract,  15,  16  150,   151 

Anterior  ethmoid  cells,  36,  47,  48,  55,  Exposure  of  maxillary  antrum,  yd,  80, 

60,  86  81,  88 

Aquaeductus    Fallopii,    121,    122,    123,  Exposure  of  middle  ear,  120,  130,  149 

131,  136,  137,  143,  148,  149,  150  Exposure   of    pituitary   gland,   40,    93, 


Asymmetry  of  sinuses.   15,  38,  40.  44, 

86       ' 
Atticus,  attic,  120,  123,  142,  143,  149 
Auditory  nerve,  143 
Auditory  process,   120 

Bulb  of  jugular  vein,  137,  142,  143 

Carotid  artery,  47,  48,  71,  -jz,  93,  136 
Carotid  canal,  136,  143 
Cavernous  sinus,  71,  72,  93,  148 
Cerebral  abscess,  130,  132,  133,  150 
Chipault's    method    of    brain    localiza- 
tion,  133,   151 
Chorda  tympani  nerve,  120 
Cochlea,  136,  142,  143 
Condyloid  vein,   137,  148 
Cribriform  plate,  59,  86 

Edema  over  mastoid  process,  106 
Eustachian  orifice,  47,  48,  68,  72 
Eustachian   tube,   47,   48,   64,   71,    103, 

136,  137,   143,   148 
Exposure  of  cerebellum,   133,   151 
Exposure  of  ethmoid  cells,  84,  89,  90, 

93 

Exposure  of  frontal  sinus,  42,  76,  78,      Hiatus  semilunaris,  59,  6'>„  74,  92 

84,  87  Horizontal       (external)       semicircular 

Exposure  of  interior  of  nose,  76,  82,  canal,  121,  123,  131,  136,  142,  143, 

90,  97  148,   149,  150 

155 


97,  100 
Exposure  of  sphenoidal  sinus,  84,  89, 

90>  93.  97 
Exposure  of  temporal  lobe,  132,  133 

External    auditory    meatus,    113,    137, 

142 
External  semicircular  canal,  123,  142 
Extradural  abscess,  130,  131,  132,  133, 

150 

Facial  nerve,  in  relation  to : 
cochlea  and  vestibule,  136,  143 
mastoid  process,  130,  136 
middle  ear,  123,  130,  131,  137,  148 
Fenestrum    ovale,    oval    window,    123, 

131,  137,  142,  148 
Fenestrum    rotundum,    round   window, 

120,  121,  130,  131,  148 
Foramen  spinosum,  133,  148 
Frontal   sinus,   36,   38,  40,  44,   42,   51, 
52 

Gasserian  ganglion,  67,  71,  72,  148 
Hiatus  Fallopii,   136,   143 


156  INDEX 

Incus,  anvil,  120,  142,  143,  149  ^louth  breathing,  effects  of,  16,  17 

Inferior  petrosal  sinus,  137,  148  at  night,  17 

Inferior  turbinal,  44,  ^2,  55,  56,  63,  64,  measures  against,  18 

67,  ;!•  'J?. 

Inflammation  of  dura  mater,   130  Xasal  appHcations,  21 

Inflammation  of  pia  mater,  130  Xasal  breathing,  effects  of,  15,  16 

Infraorbital  canal,  36  Nasofrontal  duct,  36,  87 

Infundibulum,  47,  55,  56,  5y,  92  Nasolachrymal  duct,  52,  55,  74 

Injury  to  carotid  artery,  136  Nasopharyngeal  gargling,  21,  22 

Internal    auditory    meatus,     121,     136,  Xecrosis  of  tegmen  antri,  130,  149 

142,  143  Necrosis  of  tegmen  tympani,   130,   149 
Intradural  abscess,   130,   132,   133 

Irrigation  of  frontal  sinus,  30,  31  Occipital  sinus,   14X 

Irrigation  of  maxillary  antnmi  30,  31  <  jpjj^  ^^^-^^^^^  ^^^  ^g_  ^^ 

Irrigation  of  sphenoidal  sinus,  31,  48  Osteoplastic     flap     for     exposure     of: 

frontal  sinus,  76,  80,  88 

Jugular  fossa,  131,  137,  142  interior  of  nose,  76,  97 

Jugular  vein,  136,  137,  148  maxillary  antrum,  76,  82,  89 

sphenoidal  sinus,  82,  90 

Landmarks     for     mastoid     operations,  Ostium  of  ethmoid  cells,  48,  59,  74 

122  (Jstium   of   maxillary   antrum,    36,    56, 

Lateral  sinus,   122,   123,   133,   136,   148,  59,  74 

151  Ostium  of  sphenoidal  sinus,  48,  64,  67, 
Longitudinal   sinus,    (>o.   /2,    132,    148,  71,  74 

160  Oval  window,   fenestrum  ovale,   123 

Malleus,   hammer,    120,    137,    142,    143,  Paracentesis  of  drum  membrane,    106, 

149  136 

Ivlanulirium.    handle    of    malleus,    120,  Perpendicular    (superior)    semicircular 

142  canal,  122,  136,  142,  143,  148 

Mastoid  antrum,  121,  143,  150  Petrous  portion  of  temporal  bone,  143, 

Mastoid  foramen,  121  148 

Mastoid  process,   121  Pituitary  gland,  47,  48,  71 

^lastoid  quadrants,   122,   151  Posterior  ethmoid  cells,  36,  47,  48,  60, 

Mastoid  vein,  123  63.  86 

Maxillary  antrum,   36,  40,   56,   59,  60,  Posterior  semicircular  canal,   122,   142, 

63,  64,  74,  149  148 

Middle  ear,  tympanum,  tympanic  cav-  Posture  in  otitis  media  and  mastoiditis, 

ity,  120,  137,  142,  143  103,  104 

Middle  meningeal  artery,  132,  133,  148,  Probing  of  maxillary  antrum,  92 

152  Probing   of    sphenoidal    sinus,    48,    64, 
Middle  turbinal,  44,  52,  55,  56,  59,  63,  J2,  89,  92 

64,  71,  74  Processus  brevis  of  incus,  120,  142 


IXDF.X 


157 


Processus  brevis  of  malleus.  120,  137 
Processus  cochleariforniis,   148 
Processus  longus  of  incus,    120,   142 
Proniontorium,   promontory,    120,    121, 

130,   142,   148 
Puncturing  frontal  sinus,  31 
Puncturiuf^  maxillary  antrum,  31 
Puncturing-  sphenoidal  sinus,  31,  32 
Pyriform  fossa   (bony  nasal  aperture), 

76,  90,  97 

Radical  operation  of: 

frontal  sinus,  76,  78,  80,  84,  87 
interior  of  nose,  82,  84,  90 
mastoid  process,  23,  130,  150 
maxillary  antrum,  7(1,  80,  82,  88 
middle  ear,   130,   149 
sjjhenoidal  sinus,  84,  81 ) 
Receding  chin,  cause  of,  17 
Recessus  e]3itrochlearis.  sec  .Itticiis.  at- 
tic 
Removal  of  ossicles,  149 
Rhinitis,  treatment  of  severe,  23 
Round    window,    fenestrum    rotundum, 
104,  130 

Sella  turcica,  47,  48,  /2,  93 

Shrapnell's  membrane,  120 

Sigmoid   flexure  of   lateral   sinus,    123, 

132,  136,  148 
Sphenoidal  septum,  67,  68 
Sphenoidal  sinus,  40,  47,  48,  64,  67,  68. 

9^ 
Squamous  plate  of  temporal  bone,  132, 

150 
Stapedius  muscle,  121,  123,  142 
Stapes,  120,  123,  130,  137,  142,  149 
Sternocleidomastoid  muscle.   121 
Styloid  foramen,   131,   136 
Styloid  process,   130,  148,  149 


.Suction    trc'ilmcnt.    for    maxillary    an- 
trum, 26 

for  otitis  media  and  mastoiditis,   106 

for  sinusitis,  2^ 

for  sphenoidal  sinus,  26,  48,  67 
Superficial  petrosal  nerve,   136,  143 
Superior  petrosal  sinus,    132,   148 
.Su])erior  turbinal,  Tio,  (t^,  64,  74 
Superior   (vertical)    semicircular  canal, 

142,  143,  148 
.Supraiueatic  spine,    121,   150 
Supraorbital   ridge,  36,  78,  84,  87 
."supraorbital   vessels,  87 
Syjihilitic  skull.  42 

Tegmen  antri,   130 
Tegnien    tympani,    130,    137.    148 
Temporal  muscle,    i  13,    132 
Temporal  ridge,   113,   122,   149,   150 
Tensor  tympani  muscle,   120,   123.  136, 

137,  142,  143,  148,   149 
Thrombus  in  l)idli  nf  jugular  vein,  131, 

137 
Thrombus    in    lateral    sinus,    131,    132, 

151 
Thrombus  in  jugular  vein,    137 
Thrombus  of  sigmoid  flexure  of  lateral 

sinus,   123 
Tympanic    cavity,    tympanum,    middle 

ear,   104,    120,   123,   131,    137,    143, 

148 
Tympanic    membrane,    ear   ilrum,    120, 

137,  142,  143,  149 
Tympanic   plate,    120,    130,    1 3 1,    149 

Uncinate  process,  55,   56,  91 

\  aulted  palate,  16 
A'estibule,   121,  136,  142,  143 

Zygomatic  arch,    113 


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